CD 008070

Position in the second stage of labour for women with
epidural anaesthesia (Review)

Kemp E, Kingswood CJ, Kibuka M, Thornton JG
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2013, Issue 1
http://www.thecochranelibrary.com
Position in the second stage of labour for women with epidural anaesthesia (Review)
Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ACKNOWLEDGEMENTS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Upright position versus recumbent position, Outcome 1 Operative birth (Caesarean or
instrumental vaginal). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.2. Comparison 1 Upright position versus recumbent position, Outcome 2 Duration of second stage labour
(minutes) (from time of randomisation to birth). . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.3. Comparison 1 Upright position versus recumbent position, Outcome 3 Instrumental vaginal birth. . .
Analysis 1.4. Comparison 1 Upright position versus recumbent position, Outcome 4 Caesarean section. . . . . .
Analysis 1.5. Comparison 1 Upright position versus recumbent position, Outcome 5 Trauma to birth canal requiring
suturing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.6. Comparison 1 Upright position versus recumbent position, Outcome 6 Instrumental deliveries for fetal
distress. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.7. Comparison 1 Upright position versus recumbent position, Outcome 7 Low cord pH. . . . . . .
Analysis 1.8. Comparison 1 Upright position versus recumbent position, Outcome 8 Admission to neonatal intensive care
unit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .
INDEX TERMS
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1
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2
3
3
7
9
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20
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[Intervention Review]
Position in the second stage of labour for women with

epidural anaesthesia
Emily Kemp1 , Claire J Kingswood1 , Marion Kibuka2 , Jim G Thornton3
1 Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK. 2 Maternity, East Kent Hospitals University
NHS Foundation Trust, Canterbury, UK. 3 Department of Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
Contact address: Jim G Thornton, Department of Obstetrics and Gynaecology, University of Nottingham, Nottingham City Hospital
NHS Trust, Hucknall Road, Nottingham, Nottinghamshire, NG5 1PB, UK. jim.thornton@nottingham.ac.uk.
Editorial group: Cochrane Pregnancy and Childbirth Group.
Publication status and date: New, published in Issue 1, 2013.
Review content assessed as up-to-date: 30 October 2012.
Citation: Kemp E, Kingswood CJ, Kibuka M, Thornton JG. Position in the second stage of labour for women with epidural anaesthesia.
Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD008070. DOI: 10.1002/14651858.CD008070.pub2.
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.
Objectives
To assess the effects of different birthing positions (upright versus recumbent) during the second stage of labour, on important maternal
and fetal outcomes for women with epidural analgesia.
Search methods
We searched the Cochrane Pregnancy and Childbirth Groups Trials Register (30 June 2012) 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.
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 authors to try to obtain missing data.
Main results
Five randomised controlled trials, involving 879 women, were included in the review.
Overall, we identified no statistically significant 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), 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). Nor did we identify any clear differences in the incidence of instrumental
birth or caesarean section separately, nor in any other important maternal or fetal outcome, including trauma to the birth canal requiring
suturing, operative birth for fetal distress, low cord pH or admission to neonatal intensive care unit. However, the CIs around each
estimate were wide, and clinically important effects have not been ruled out.
There were no data reported on excess blood loss, 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.
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. Women with an epidural should be encouraged to use whatever position they find comfortable in the second stage of labour.
Future research should involve large trials of positions that women can maintain and predefined endpoints. One large trial is ongoing.
PLAIN LANGUAGE SUMMARY

Upright or recumbent positions in late labour for women using an epidural for pain relief in labour
An epidural is the most effective method for pain relief during labour. It is often used by women even though it can prolong labour
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. 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.
BACKGROUND
Epidural analgesia is commonly used as a form of pain relief in
labour. Systematic reviews of randomised controlled trials (RCTs)
have found that it is more effective than other non-epidural
methods (Anim-Somuah 2005). However, epidurals result in a
longer second stage of labour and more instrumental deliveries
(Anim-Somuah 2005). This matters because prolonged second
stage of labour may increase the risk of fetal respiratory acidosis
and postpartum haemorrhage (Watson 1994). Instrumental deliveries are associated with prolapse, urinary incontinence, and dyspareunia (painful intercourse) (Liebling 2004; MacLennan 2000).
A survey during 2005 and 2006 showed that 22% of all deliveries
in UK NHS hospitals involve an epidural (Richardson 2007); in
other countries, for example, Canada, epidural rates may be even
higher. This is why strategies to shorten the second stage of labour
and reduce instrumental deliveries in this setting are important.
There are several proposed mechanisms for the association between
epidurals and increased instrumental deliveries. Epidurals increase
the risk of malposition of the fetal head, in particular the fetal
occiput-posterior position, a key factor in instrumental birth and
prolonged labour (Lieberman 2005; Martino 2007). Secondly,

epidurals may interfere with the release of oxytocin as the pelvic
floor stretches in the late second stage of labour (Goodfellow 1983;
Rahm 2002). Finally, epidurals may inhibit the mothers bearing
down reflex at the same time.
With the advancement of low-dose epidural techniques, also
known as walking epidurals, women with an epidural are now
being provided with the opportunity to remain mobile during
their labour, and to adopt some upright positions such as standing and ambulation which may not be possible for women with a
traditional epidural (COMET 2001). The use of ambulation during labour has been associated with more efficient uterine action,
labours of a shorter duration, and aiding the descent of the fetal
head through encouraging the effects of gravity (COMET 2001;
Flynn 1978). The use of low-dose epidurals is also thought to aid
the maternal efforts required to give birth through the preservation of motor function (COMET 2001). The increased number
of vaginal deliveries seen with this form of analgesia is thought to
be due to the ability of the women to adopt an upright position
during labour (COMET 2001).

One suggestion to reduce adverse outcomes in labour with an
epidural is the use of alternative maternal birth positions. Although it has become more common in the West to deliver in
the supine position, this position may result in a higher number
of instrumental deliveries and episiotomies (De Jonge 2004). In
women without an epidural, a number of observational studies
have suggested that delivering in an upright position results in
shorter labours, lower incidence of instrumental deliveries and episiotomies, and is a more comfortable birth position (Bodner-Adler
2003; Mendez-Bauer 1975). Some small RCTs (for example, Chen
1987) and two systematic reviews (De Jonge 2004; Gupta 2004)
have confirmed this. It has been proposed that these benefits are
due to a higher resting intrauterine pressure which contributes
to the downward birth force and the bearing-down forces (Chen
1987), as well as contractions of a greater intensity (Mendez-Bauer
1975).
Another possible way to facilitate spontaneous birth would be positions that take the body weight off the sacrum and allow the
pelvic outlet to expand. Although it would be possible to classify
positions into weight on and weight off the sacrum, and examine trials that compared such positions, this has not been done
in the present review.
Although a Cochrane review (Gupta 2004) has assessed the use
of upright positions in the second stage of labour, it did not include women with epidurals, and therefore the findings can not
be generalised. The benefits noted in women without an epidural
may potentially offset some of the effect an epidural may have on
prolongation of labour, and highlights the importance of carrying
out this systematic review. The present review will test the effect
of vertical versus horizontal positions in women with all types of
epidural. We recognise that some vertical positions, e.g. ambulation, standing and squatting, as well as some horizontal positions e.g. knee chest, may be difficult for women with a traditional
epidural to maintain. However, other vertical positions, e.g. sitting supported, are possible even with a traditional epidural, so we
have included traditional epidurals in the analysis.
A recent non-Cochrane review (Roberts 2005) attempted just this;
however, it was unable to report any data for the fetal outcomes
because the trials did not make this information available. Therefore, it is our aim to apply the more stringent Cochrane approach,
which would involve contacting authors where data are missing,
in evaluating this much disputed aspect of obstetrics.
OBJECTIVES
To assess the effects of different birthing positions during the second stage of labour, on important maternal and fetal outcomes for
women with epidural analgesia.
METHODS
Criteria for considering studies for this review
Types of studies
All randomised or quasi-randomised trials.
Types of participants
All pregnant women (primigravidae and multigravidae) in the second stage of induced or spontaneous labour receiving epidural
analgesia. We included women with any type of epidural. We included women recruited and randomised in any stage of labour. We
only included singleton pregnancies at term gestation (37 weeks
+ zero days).
Types of interventions
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. We included trials in which the intervention (upright or recumbent) was confined to the second stage of labour,
and also where it was performed in the first stage of labour but
also continued into the second stage.
The second stage of labour can be divided into two distinct phases:
the latent phase (also known as the passive phase), and the active
phase. We define the latent phase as the period of time from full
dilatation until the head has descended to the pelvic floor, with
the mother experiencing no desire to push. We define the active
phase as the period from the head descending to the pelvic floor
until the birth of the baby, with the mother having a strong desire
to push (ODriscoll 2003).
We classified studies as either a comparison of an upright versus
a recumbent position in the latent phase of the second stage of
labour, or a comparison of an upright versus a recumbent position
in the active phase of the second stage of labour. We considered
studies eligible for inclusion if it was intended that participants
spent at least 30% of time in the relevant phase of second stage
labour in the allocated position. Finally, studies that compared
an upright position in both phases of the second stage with a
recumbent position in both phases of the second stage formed a
third group. There are three potential time phases in which the
effects of different positions can be studied: namely the latent
phase; the active; and both.
We initially categorised the birthing positions as upright (the main
axis of the body was more than 45 from the horizontal) or recumbent (the main axis of the body was less than 45 from the
horizontal).
Upright positions included:
sitting (on a bed);

sitting (on a tilting bed more than 45 from the horizontal);
squatting (unaided or using squatting bars);
squatting (aided with birth cushion);
semi-recumbent (we classed this as an upright position if
the main axis of the body (chest and abdomen) was 45 or more
from the horizontal);
kneeling (upright, leaning on the head of the bed, or
supported by a partner);
walking (only for comparison of positions in the latent
phase).
Recumbent positions included:
lithotomy position;
lateral position (left or right);
Trendelenburgs position (head lower than pelvis);
knee-elbow (all fours) position; this is considered
recumbent because the axis of the trunk is horizontal;
semi-recumbent (we classed this as a recumbent position if
the main axis of the body (chest and abdomen) was less than 45
from the horizontal).
A number of other names have been used for birthing positions,
including:
Fowler;
tug-of-war;
throne.
We delayed classifying these until after we had identified the trials.
We planned to classify them from the methods section without
knowledge of the trial results, again, using the dividing line of the
body at 45 from the horizontal.
Some trials may compare positions with varying degrees of uprightness, which fall the same side of the 45 dividing line. For
example, a study might compare the horizontal position (0) with
semi-recumbent (40). So long as the two groups clearly differ in
degree of verticality, we classified them as more vertical and less
vertical. We excluded such studies from the primary analysis, but
included them in a secondary sensitivity analysis.
No studies reporting Fowler, tug of war or throne positions and
no more vertical/less vertical studies were found.
Types of outcome measures
Primary outcomes
Maternal outcomes
1. Operative birth (defined as caesarean section or vaginal
instrumental birth)
2. Duration of second stage labour. (Since the assessment of
the onset of 2nd stage is susceptible to bias, we reported and
analysed the randomisation to birth interval, where available)
Secondary outcomes
Maternal outcomes
1. Caesarean section
2. Instrumental birth (forceps or ventouse (vacuum))
3. Trauma to birth canal, requiring suturing
4. Blood loss (greater than 500 mL) (or as defined by trial
authors)
5. Prolonged second stage, defined as pushing for more than
60 minutes (or as defined by trial authors)
6. Maternal experience and satisfaction of labour
Baby outcomes
1. Abnormal fetal heart rate patterns, requiring intervention
2. Apgar score of less than seven at five minutes (or as defined
by trial authors)
3. Low cord pH less than 7.1 (or as defined by trial authors)
(Following examination of the included studies, it was found
that only one study had recorded low cord pH and this was
recorded as less than 7.2, whereas it was stated here that it would
be less than 7.1. Therefore, it has been left undefined and
included in the study as Low cord pH.)
4. Admission to neonatal intensive care unit
5. Need for ventilation
6. Perinatal death
Search methods for identification of studies
Electronic searches
We contacted the Trials Search Co-ordinator to search the
Cochrane Pregnancy and Childbirth Groups Trials Register (30
June 2012).
The Cochrane Pregnancy and Childbirth Groups Trials Register
is maintained by the Trials Search Co-ordinator and contains trials
identified from:
1. monthly searches of the Cochrane Central Register of
Controlled Trials (CENTRAL);
2. weekly searches of MEDLINE;
3. weekly searches of EMBASE;
4. handsearches of 30 journals and the proceedings of major
conferences;
5. weekly current awareness alerts for a further 44 journals
plus monthly BioMed Central email alerts.
Details of the search strategies for CENTRAL, MEDLINE and
EMBASE, the list of handsearched journals and conference proceedings, and the list of journals reviewed via the current awareness service can be found in the Specialized Register section
within the editorial information about the Cochrane Pregnancy

and Childbirth Group.
Trials identified through the searching activities described above
are each assigned to a review topic (or topics). The Trials Search
Co-ordinator searches the register for each review using the topic
list rather than keywords.
Searching other resources
We searched the reference lists of retrieved studies.
We did not apply any language restrictions.
Data collection and analysis
unclear risk of bias.
(2) Allocation concealment (checking for possible selection

bias)
We described for each included study the method used to conceal

the allocation sequence and determine whether intervention allocation could have been foreseen in advance of, or during recruitment, or changed after assignment.
We assessed the methods as:
low risk of bias (e.g. telephone or central randomisation;
consecutively numbered sealed opaque envelopes);
high risk of bias (open random allocation; unsealed or nonopaque envelopes, alternation; date of birth);
Selection of studies
Review authors Emily Kemp (EK) and Jim Thornton (JT) independently assessed for inclusion all the potential studies we identified as a result of the search strategy. We resolved any disagreement
through discussion or, where required, we consulted a third review
author.
Data extraction and management

We designed a form to extract data. For eligible studies, EK and JT
extracted the data using the agreed form. We resolved discrepancies
through discussion or, if required, we consulted a third review
author. We entered data into Review Manager software (RevMan
2011) and checked them for accuracy.
When information regarding any of the above was unclear, we
attempted to contact authors of the original reports to provide
further details.
Assessment of risk of bias in included studies
EK and JT independently assessed risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic
Reviews of Interventions (Higgins 2011). We resolved any disagreement by discussion or by involving a third assessor.
(1) Sequence generation (checking for possible selection

bias)
We described for each included study the method used to generate

the allocation sequence in sufficient detail to allow an assessment
of whether it should produce comparable groups.
We assessed the method as:
low risk of bias (any truly random process, e.g. random
number table, computer random number generator);
high risk of bias (any non-random process, e.g. odd or even
date of birth) hospital or clinic record number);
(3) Blinding (checking for possible performance bias)
We described for each included study the methods used, if any, to

blind study participants and personnel from knowledge of which
intervention a participant received. We considered that studies
were at low risk of bias if they were blinded, or if we judged that the
lack of blinding could not have affected the results. We assessed
blinding separately for different outcomes or classes of outcomes.
low, high or unclear risk of bias for participants;
low, high or unclear risk of bias for personnel;
low, high or unclear risk of bias for outcome assessors.
(4) Incomplete outcome data (checking for possible attrition

bias through withdrawals, dropouts, protocol deviations)
We described for each included study, and for each outcome or

class of outcomes, the completeness of data including attrition and
exclusions from the analysis. We state whether attrition and exclusions were reported, the numbers included in the analysis at each
stage (compared with the total randomised participants), reasons
for attrition or exclusion where reported, and whether missing data
were balanced across groups or were related to outcomes. Where
sufficient information was reported, or could be supplied by the
trial authors, we re-included missing data in the analyses which
we undertook. We assessed methods as:
low risk of bias (e.g. defined as less than five per cent
missing data for the particular outcome);
high risk of bias (e.g. numbers or reasons for missing data
imbalanced across groups; as treated analysis done with
substantial departure of intervention received from that assigned
at randomisation);
(5) Selective reporting bias
Dealing with missing data
We described for each included study how we investigated the

possibility of selective outcome reporting bias and what we found.
low risk of bias (where it was clear that all of the studys prespecified outcomes and all expected outcomes of interest to the
review had been reported);
high risk of bias (where not all the studys pre-specified
outcomes were reported; one or more reported primary
outcomes were not pre-specified; outcomes of interest were
reported incompletely and so could not be used; study failed to
include results of a key outcome that would have been expected
to have been reported);
For included studies, we noted levels of attrition. We explored the

impact of including studies with high levels of missing data in the
overall assessment of treatment effect by using sensitivity analysis.
For all outcomes, we carried out analyses, as far as possible, on
an intention-to-treat basis, i.e. we attempted to include all participants randomised to each group in the analyses, and all participants were analysed in the group to which they were allocated, regardless of whether or not they received the allocated intervention.
The denominator for each outcome in each trial was the number
randomised minus any participants whose outcomes were known
to be missing.
(6) Other sources of bias
We described for each included study any important concerns we

had about other possible sources of bias.
We assessed whether each study was free of other problems that
could put it at risk of bias:
low risk of other bias;
high risk of other bias;
unclear whether there is risk of other bias.
(7) Overall risk of bias
We make explicit judgements about whether studies are at high risk

of bias, according to the criteria given in the Handbook (Higgins
2011). With reference to (1) to (6) above, we assessed the likely
magnitude and direction of the bias and whether we considered
it was likely to impact on the findings. We explored the impact
of the level of bias through undertaking sensitivity analyses - see
Sensitivity analysis.
Measures of treatment effect
Dichotomous data
For dichotomous data, we present results as summary risk ratio

with 95% confidence intervals.
Assessment of heterogeneity
We assessed statistical heterogeneity in each meta-analysis using
the T, I and Chi statistics. We regard heterogeneity as substantial if I is greater than 30% and either T is greater than zero, or
there is a low P value (less than 0.10) in the Chi test for heterogeneity.
Assessment of reporting biases
In future updates of this review, if there are 10 or more studies
in the meta-analysis we will investigate reporting biases (such as
publication bias) using funnel plots. We will assess funnel plot
asymmetry visually, and use formal tests for funnel plot asymmetry.
For continuous outcomes, we will use the test proposed by Egger
1997, and for dichotomous outcomes, we will use the test proposed
by Harbord 2006. If asymmetry is detected in any of these tests
or is suggested by a visual assessment, we will perform exploratory
analyses to investigate it.
Data synthesis
We carried out statistical analysis using the Review Manager software (RevMan 2011). Since all analyses included trials comparing
different vertical and horizontal positions, we used the random-effects model throughout. The random-effects summary was treated
as the average range of possible treatment effects and we discuss
the clinical implications of treatment effects differing between trials. If the average treatment effect was not clinically meaningful
we did not combine trials.
For random-effects analyses, the results are presented as the average treatment effect with its 95% confidence interval, and the
estimates of T and I.
Continuous data
Subgroup analysis and investigation of heterogeneity
For continuous data, we used the mean difference if outcomes

were measured in the same way between trials. We used the standardised mean difference to combine trials that measured the same
outcome, but used different methods.
If we had identified substantial heterogeneity, we planned to investigate it using subgroup analyses and sensitivity analyses. We
considered whether an overall summary was meaningful, and if it
was, used random-effects analysis to produce it.
We planned to carry out the following subgroup analyses.

1. Time of epidural: sited in the first stage of labour or sited in
the second stage of labour.
2. Type of epidural: traditional versus walking. We classified
low-dose combined spinal epidurals and low-dose infusion
epidurals as walking.
3. Nulliparous versus multiparous women.
4. Oxytocin used/not used in the second stage.
Due to insufficient data we were not able to carry out subgroup
analyses 1, 3 and 4. However, these will be carried out in future
updates of this review as more data become available.
The following outcomes were used in subgroup analysis.
Operative birth. Caesarean section or instrumental vaginal
birth.
Duration of second stage labour. (Since the assessment of
the onset of 2nd stage is susceptible to bias, we report and analyse
the randomisation to birth interval, where available).
See: Characteristics of included studies; Characteristics of excluded

studies; Characteristics of ongoing studies.
For fixed-effect inverse variance meta-analyses we will assess differences between subgroups by interaction tests. For random-effects and fixed-effect meta-analyses using methods other than inverse variance, we will assess differences between subgroups by inspection of the subgroups confidence intervals; non-overlapping
confidence intervals indicate a statistically significant difference in
treatment effect between the subgroups.
Five studies, involving 879 women, were included in the review,

see Characteristics of included studies.
All the included studies had two intervention groups which could
be classified into an upright or recumbent position using the criteria in the Methods section.
Downe 2004, compared lateral (left or right facing positions)
and sitting positions (supported upright sitting position). Golara
2002 compared recumbent (as much time as possible in bed or a
chair) and upright (as much time as possible during the passive
phase either standing or walking) and after one hour, their chosen pushing position was allowed. Boyle 2001 compared ambulant (walking around for at least 15 minutes every hour, up to the
point of active voluntary pushing) and non-ambulant (usual care,
where the women were non-ambulant except for the majority of
the labour). Karraz 2003 compared ambulatory (walking, sitting
in a chair, reclining in semi-supine position) with non-ambulatory (not allowed to sit or walk, had to remain in the supine, semisupine or lateral position). Theron 2011 compared a sitting position with a lateral position during the passive second stage of
labour, usually one hour.
Three studies (Downe 2004; Golara 2002; Theron 2011) specifically restricted the period of randomisation to the second stage of
labour. One study Boyle 2001, explicitly, and one Karraz 2003,
implicitly, also included the first stage of labour within the period
of randomisation. However, since both studies included the passive second stage within the period of randomisation, we have included them in the present review. We recognise that there will be
some overlap between these studies and the Cochrane review Maternal positions and mobility in the first stage of labour (Lawrence
2009).
All the studies had their own entry and exclusion criteria which
can be seen in the Characteristics of included studies table.
All studies reported instrumental birth, caesarean section and
spontaneous vaginal birth. Trauma to the birth canal requiring suturing was reported by two (Downe 2004; Golara 2002). Downe
Sensitivity analysis
We planned to carry out sensitivity analyses but none of the included studies met our prespecified criteria. In future updates of
this review we will carry out the following sensitivity analysis,
where appropriate.
The primary analysis includes all randomised trials comparing upright with recumbent positions as defined. We will carry out sensitivity analysis to explore the effect of trial quality. This will involve
an analysis limited to high-quality trials. This will be defined as
follows.
Restricting analysis to those trials with adequate risk of bias judgements for allocation concealment and incomplete outcome data.
For the outcomes perinatal death, mode of birth and duration
of second stage (randomisation to birth), we will include studies
where the outcome assessor was not blinded. For all other outcomes, we will exclude studies where the outcome assessor was not
blinded from this high-quality analysis.
We will also perform a second sensitivity analysis including trials
comparing more vertical with less vertical as defined.
RESULTS
Description of studies
Results of the search

The search of the Cochrane Pregnancy and Childbirth Groups
Trials Register identified eight reports of seven trials. Four trials were included (Downe 2004; Golara 2002; Karraz 2003;
Theron 2011) and three excluded (Asselineau 1996; Collis 1999;
Danilenko-Dixon 1996). One trial is ongoing (Brocklehurst
2010), see Characteristics of ongoing studies.
A further trial report (Collis 1999) was identified after looking
through the references of the trials found on the Trials Register,
and was excluded. One additional report was identified (Boyle
2001) and included.
Included studies
2004, was the only study to report instrumental deliveries for fetal
distress. Golara 2002 was the only study to report low cord pH and
admission to neonatal intensive care unit. The duration of second
stage of labour was reported by Downe 2004 and Karraz 2003.
Golara 2002, also reported duration of second stage of labour but,
only the median and range. We contacted the trial author to see if
the raw data or mean and standard deviations were available but
these were not obtained so the data could not be included in the
review.
Excluded studies
We excluded three studies (Asselineau 1996; Collis 1999;
Danilenko-Dixon 1996). One study was excluded because it
was not a randomised controlled trial (Asselineau 1996). Collis
1999 was excluded because it compared upright versus recumbent position in the first stage of labour only (when cervical dilation was identified, the women returned to their beds). The
Danilenko-Dixon 1996 study was excluded because it did not
compare an upright position with a lateral position (it compared
two recumbent positions (supine and lateral).
For more details, see Characteristics of excluded studies.
Risk of bias in included studies
Allocation
Four trials reported either using computer-generated random
numbers (Boyle 2001; Downe 2004; Golara 2002; Theron 2011)
and one in which participants were randomly divided into two
groups (Karraz 2003).
Three of the four used opaque envelopes (Downe 2004) or sealed
brown envelopes (Golara 2002) or sealed envelopes (Boyle 2001),
but since the numbering, sealed status, or opacity of the envelopes
was not reported in all cases, the risk of bias was judged to be
unclear. Two trials (Karraz 2003; Theron 2011) did not report
the allocation sequence concealment (Karraz 2003; Theron 2011).
Selective reporting
Theron 2011 was rated as being at high risk of reporting bias
because the secondary outcomes of maternal acceptability, cardiotocograph (CTG) abnormality and neonatal outcomes were
not reported and the trial protocol was not registered. Trial protocols were not registered for the other four trials (Boyle 2001;
Downe 2004; Golara 2002; Karraz 2003) and these were rated as
Other potential sources of bias

None of the studies had independently registered their sample size,
primary endpoint or other aspects of the analysis plan. Only one
(Theron 2011) reported that the intended sample size of 300 was
larger than the achieved one of 77.
Effects of interventions
Data were identified for eight meta-analyses to be performed.
Primary outcomes
Overall, we identified no statistically significant difference between
upright and recumbent positions on the primary outcomes operative birth (caesarean or instrumental vaginal) (average risk ratio
(RR) 0.97; 95% confidence interval (CI) 0.76 to 1.25; five trials, 874 women; random-effects, Tau = 0.04; I = 54% (Analysis
1.1)), or duration of the second stage of labour measured as the randomisation to birth interval in minutes (average mean difference
(MD) -22.98; 95% CI -99.09 to 53.13; two trials, 322 women;
random-effects, Tau = 2791.90; I = 92% (Analysis 1.2)). Note
the high degree of heterogeneity between the two trials included
in the duration of second stage analysis.
Blinding
Secondary outcomes
In none of the studies were the patient or the assessor masked to

the treatment allocation.
We identified no statistically significant differences between upright and recumbent position on instrumental birth (average RR
1.02; 95% CI 0.81 to 1.28; five trials, 874 women; random-effects, Tau = 0.02; I = 25% (Analysis 1.3)) or caesarean section
(average RR 0.81; 95% CI 0.38 to 1.69; five trials, 874 women;
random-effects, Tau = 0.30, I = 51% (Analysis 1.4)). Nor did we
identify any significant effects on trauma to birth canal requiring
suturing (average RR 0.95; 95% CI 0.66 to 1.37; two trials, 173
women; random-effects, Tau = 0.05, I = 74% (Analysis 1.5)).
There were no data reported on excess blood loss, prolonged second stage or maternal experience and satisfaction with labour.
Incomplete outcome data

Two studies (Boyle 2001; Downe 2004) reported results for all
participants randomised, but the others were classed as having an
unclear (Golara 2002; Karraz 2003) or high (Theron 2011) risk
of bias from post randomisation exclusions. Theron 2011 reported
43 participants who dropped out after consent but did not clarify
if this was also post randomisation.
Baby outcomes
We identified no significant differences in baby outcomes; instrumental deliveries for fetal distress (RR 1.69; 95% CI 0.32 to 8.84;
one trial, 107 women (Analysis 1.6)), low cord pH (RR 0.61; 95%
CI 0.18 to 2.10; one trial, 66 infants (Analysis 1.7)), or admission
to neonatal intensive care unit (RR 0.54; 95% CI 0.02 to 12.73;
one trial, 66 infants (Analysis 1.8)). There were no analysable data
on Apgar scores, and no data reported on need for ventilation or
perinatal death.
DISCUSSION
Summary of main results

This review included five randomised controlled trials, involving
879 women.
We identified no clinically important or statistically significant
effects of upright compared with recumbent positions on any of
the predefined outcomes, namely, total operative birth (caesarean
or instrumental vaginal), duration of second stage of labour, caesarean section, instrumental birth, trauma to birth canal requiring suturing, low cord pH or admission to neonatal intensive care
unit.
Overall completeness and applicability of

evidence
This review includes all available randomised controlled trials
which test the theory of whether gravity might help the process of
birth.
Quality of the evidence

The studies were relatively small so the confidence intervals around
each effect size were large. All of the studies had some methodological concerns lack of registration, unclear randomisation concealment, or post randomisation exclusions which mean the results
should be interpreted with caution. The studies also compared
different upright and recumbent positions, which may explain the
heterogeneity observed between Downe 2004 and the other trials.
One study (Downe 2004) involved women with traditional epidurals, three (Boyle 2001; Golara 2002; Karraz 2003) women with
walking epidurals and one (Theron 2011) did not report the type
of epidural. These differences may also partly explain the heterogeneity of the results.
Since the confidence intervals around each estimate were wide,
clinically important effects were not ruled out, so women with an
epidural should be encouraged to use whatever position they find

most comfortable during their second stage of labour.
There was some heterogeneity among the five studies in their effect
on instrumental vaginal birth, and a very large and highly statistically significant degree of heterogeneity among the two studies
(Downe 2004; Karraz 2003) that recorded duration of the second stage. For both outcomes the trial by Downe 2004 differed,
namely more instrumental deliveries and a longer second stage in
the upright group. One explanation is potential bias from failure of
randomisation (Karraz 2003) or allocation concealment (Downe
2004; Karraz 2003). Another, is that the Downe 2004 trial compared sitting (upright) with the left/right lateral (recumbent) position. The benefits of the upright position may be negated if
the woman rests on the sacrum and ischial tuberosities (Gardosi
1989). This may rotate the sacrum forward and reduce the anterior posterior pelvic outlet dimensions (Borell 1957).
In the present review we have not considered studies which assesses
positions which free the pelvis to expand a little compared with
those where the pelvis is fixed. Such a comparison would test if
positions which let the pelvis expand and give more room for the
baby to pass through, might help. Sitting upright on a bed would
be a pelvis fixed position. This comparison will be considered
in the next update.
Potential biases in the review process

It is possible that since the studies were carried out on women
who had the type of epidural that allowed them to ambulate then
these may not be the population of women who would have had
a longer second stage in the first place.
Agreements and disagreements with other

studies or reviews
The confidence intervals around the effects seen in the present
review are within the effect sizes seen for the upright positions in
women without epidural analgesia (Gupta 2004).
AUTHORS CONCLUSIONS
Implications for practice
The result of this review shows that there are insufficient data on
which to base a recommendation about the best position for the
second stage of labour for women with an epidural. They should
be encouraged to use the position that they feel most comfortable
in, during the second stage of labour.
Implications for research

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. Such 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.
ACKNOWLEDGEMENTS
As part of the pre-publication editorial process, this review has
been commented on by three peers (an editor and two referees
who are external to the editorial team), a member of the Pregnancy
and Childbirth Groups international panel of consumers and the
Groups Statistical Adviser.
REFERENCES
References to studies included in this review

Boyle 2001 {published data only}
Boyle S, Entwistle F, Hamilton C, Kulinska E. A randomised
controlled trial examining the effect of ambulation on
labour outcome who choose a combined spinal epidural
for pain relief in labour. International Confederation of
Midwives. Midwives and women working together for
the family of the world: ICM Proceedings; 2002; Vienna,
Austria. 2002:111.
Downe 2004 {published data only}
Downe S, Gerrett D, Renfrew MJ. A prospective randomised
trial on the effect of position in the passive second stage
of labour on birth outcome in nulliparous women using
epidural analgesia. Midwifery 2004;20:15768.
Golara 2002 {published data only}
Golara M, Shennan AH. Upright versus recumbent

position in the second stage of labour in women with
combined spinal-epidural analgesia. International Journal of
Obstetric Anesthesia 2002;11:1922.
Plaat F, Golara M, Shennan A. Upright vs recumbent
position with mobile extradurals in the early second stage of
labour. British Journal of Anaesthesia 1996;76:102.
Karraz 2003 {published data only}
Karraz MA. Ambulatory epidural anesthesia and the
duration of labor. International Journal of Gynecology &
Obstetrics 2003;80:11722.
Theron 2011 {published data only}
Theron A, Baraz R, Thorp-Jones D, Sanders J, Collis
R. Does postition in the passive second stage of labour
affect birth outcome in nulliparous women using epidural
analgesia. Internatinal Journal of Obstetric Anesthesia 2011;
20(Suppl 1):S12.
References to studies excluded from this review

Asselineau 1996 {published data only}
Asselineau D. Does ambulation under epidural analgesia
during labor modify the conditions of fetal extraction? [La
deambulation sous peridurale lors du travail modifietelle

les conditions dextraction foetale?]. Contraception, Fertilite,
Sexualite 1996;24(6):5058.
Collis 1999 {published data only}
Collis R, Harding S, Morgan B. Effect of maternal
ambulation on labour with low-dose combined spinalepidural analgesia. Anaesthesia 1999;54:5359.
Danilenko-Dixon 1996 {published data only}
Danilenko-Dixon DR, Tefft L, Cohen RA, Haydon B,
Carpenter MW. Positional effects on maternal cardiac
output during labor with epidural analgesia. American
Journal of Obstetrics and Gynecology 1996;175:86772.
References to ongoing studies

Brocklehurst 2010 {published data only}
Brocklehurst P. Upright maternal position in second stage
labour in women with epidural analgesia; a randomised
controlled trial. http://www.hta.ac.uk/ (accessed 27 January
2010).
Additional references
Anim-Somuah 2005
Anim-Somuah M, Smyth R, Howell C. Epidural versus
non-epidural or no analgesia in labour. Cochrane Database
of Systematic Reviews 2005, Issue 4. [DOI: 10.1002/
14651858.CD000331.pub2]
Bodner-Adler 2003
Bodner-Adler B, Bodner K, Kimberger O, Lozanov P,
Husslein P, Mayerhofer K. Womens position during labour:
influence on maternal and neonatal outcome. Wiener
Klinische Wochenschrift 2003;115:7203.
Borell 1957
Borell V, Fernstrom I. A pelvimetric method for the
assessment of pelvic mouldability. Acta Radiologica 1957;47
(5):36570.
10
Chen 1987
Chen SZ, Aisaka K, Mori H, Kigawa T. Effects of sitting
position on uterine activity during labor. Obstetrics &
Gynecology 1987;69:6773.
COMET 2001
Comparative Obstetric Mobile Epidural Trial (COMET)
Study Group UK. Effect of low-dose mobile versus
traditional epidural techniques on mode of delivery: a
randomised controlled trial. Lancet 2001;358:1923.
De Jonge 2004
De Jonge A, Teunissen TA, Lagro-Janssen AL. Supine
position compared to other positions during the second stage
of labor: a meta-analytic review. Journal of Psychosomatic
Obstetrics & Gynecology 2004;25:3545.
Egger 1997
Egger M, Davey Smith G, Schneider M, Minder C. Bias
in meta-analysis detected by a simple, graphical test. BMJ
1997;315(7109):62934.
Flynn 1978
Flynn AM, Kelly J, Hollins G, Lynch PF. Ambulation in
labour. British Medical Journal 1978;2:5913.
Gardosi 1989
Gardosi J, Hutson N, B-Lynch C. Randomised, controlled
trial of squatting in the second stage of labour. Lancet 1989;
Vol. 2, issue 8654:747.
Goodfellow 1983
Goodfellow CF, Hull MG, Swaab DF, Dogterom J, Buijs
RM. Oxytocin deficiency at delivery with epidural analgesia.
British Journal of Obstetrics and Gynaecology 1983;90(3):
2149.
Gupta 2004
Gupta JK, Hofmeyr GJ, Smyth R. Position in the second
stage of labour for women without epidural anaesthesia.
Cochrane Database of Systematic Reviews 2004, Issue 1.
[DOI: 10.1002/14651858.CD002006.pub2]
Harbord 2006
Harbord RM, Egger M, Sterne JA. A modified test for
small-study effects in meta-analyses of controlled trials
with binary endpoints. Statistics in Medicine 2006;25(20):
344357.
Higgins 2011
Higgins JPT, Green S, editors. Cochrane Handbook for
Systematic Reviews of Interventions Version 5.1.0 [updated
March 2011]. The Cochrane Collaboration, 2011.
Available from www.cochrane-handbook.org.
Lawrence 2009
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.
[DOI: 10.1002/14651858.CD003934.pub2]
Lieberman 2005
Lieberman E, Davidson K, Lee-Parritz A, Shearer E.
Changes in fetal position during labor and their association
with epidural analgesia. Obstetrics & Gynecology 2005;105:
97482.
Liebling 2004
Liebling RE, Swingler R, Patel RR, Verity L, Soothill PW,
Murphy DJ. Pelvic floor morbidity up to one year after
difficult instrumental delivery and cesarean section in the
second stage of labor: a cohort study. American Journal of
Obstetrics and Gynecology 2004;191:410.
MacLennan 2000
MacLennan AH, Taylor AW, Wilson DH, Wilson D. The
prevalence of pelvic floor disorders and their relationship
to gender, age, parity and mode of delivery. BJOG: an
international journal of obstetrics and gynaecology 2000;107:
146070.
Martino 2007
Martino V, Iliceto N, Simeoni U. Occipito-posterior fetal
head position, maternal and neonatal outcome. Minerva
Ginecologica 2007;59:45964.
Mendez-Bauer 1975
Mendez-Bauer C, Arroyo J, Garcia Ramos C, Menendez A,
Lavilla M, Izquierdo F, et al.Effects of standing position on
spontaneous uterine contractility and other aspects of labor.
Journal of Perinatal Medicine 1975;3:89100.
ODriscoll 2003
ODriscoll K, Meagher D, Robson, M. Active Management
of Labour. Elsevier Health Sciences, 2003.
Rahm 2002
Rahm VA, Hallgren A, Hogberg H, Hurtig I, Odlind
V. Plasma oxytocin levels in women during labor with
or without epidural analgesia: a prospective study. Acta
Obstetricia et Gynecologica Scandinavica 2002;81:10339.
RevMan 2011
The Nordic Cochrane Centre, The Cochrane Collaboration.
Review Manager (RevMan). 5.1. Copenhagen: The Nordic
Cochrane Centre, The Cochrane Collaboration, 2011.
Richardson 2007
Richardson A, Mmata C. NHS Maternity Statistics, England:
2005-2006. NHS Infomation Centre, 2007.
Roberts 2005
Roberts CL, Algert CS, Cameron CA, Torvaldsen S. A
meta-analysis of upright positions in the second stage to
reduce instrumental deliveries in women with epidural
analgesia. Acta Obstetricia et Gynecologica Scandinavica
2005;84:7948.
Watson 1994
Watson V. The duration of the second stage of labour.
Modern Midwife 1994;4:212.
Indicates the major publication for the study
11
CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]

Boyle 2001
Methods
A randomised controlled trial in a consultant maternity unit in Hertfordshire

Participants were recruited between August 1999 and December 2000
Participants
Primiparous (n = 295) and multiparous (n = 113) women (total 408) in either induced
or spontaneous labour with a working low dose, CSE in the first stage of labour, and a
Modified Bromage score of greater than or equal to 3
Interventions
The ambulant group were encouraged to walk around for at least 15 minutes in every
hour, up to the point of active voluntary pushing, i.e. including the passive second stage
of labour
The non-ambulant group received usual care. This meant remaining non-ambulant
except for toilet purposes for the majority of the labour
Among primigravidae the mean time in minutes spent ambulating (SD) was 46 (51) in
the ambulant group and 18 (33) in the non-ambulant. Among multigravidae the mean
time in minutes spent ambulating (SD) was 37 in the ambulant group and 11 in the
non-ambulant. Note standard deviations were not reported for multigravidae
Use of oxytocin in the second stage was not reported.
Outcomes
Maternal outcomes
1. Operative birth
2. Instrumental birth
4. Trauma to birth canal. Not reported
5. Blood loss. Not reported
6. Prolonged second stage. Not reported
7. Maternal experience and satisfaction of labour. Data collected but not reported
Baby outcomes
1. Abnormal fetal heart rate patterns, needing intervention. Not reported
2. Apgar scores at 1 and 5 minutes. Reported only as means.
3. Low cord pH not reported
4. Admission to neonatal intensive care unit. Not reported
5. Need for ventilation. Not reported.
6. Perinatal death. Not reported
Notes
Risk of bias
Bias
Authors judgement
Random sequence generation (selection Low risk

bias)
Support for judgement

A computer-generated random number sequence was used.
12
Boyle 2001
(Continued)
Allocation concealment (selection bias)
Unclear risk
Randomisation was achieved by the use

of sequentially numbered sealed envelopes.
Opacity not reported
Blinding (performance bias and detection Low risk

bias)
All outcomes
The trial was unavoidably unblinded, but

there was no evidence of any performance
bias in terms of different analgesic co-interventions, and the main outcomes were all
objective
Incomplete outcome data (attrition bias)

All outcomes
Low risk
No losses to follow-up recorded and only

short-term outcomes reported
Selective reporting (reporting bias)
Unclear risk
Neither the trial, nor the protocol was registered.
Other bias
Unclear risk
The trial protocol was not registered.
Downe 2004
Methods
A pragmatic prospective randomised controlled trial, in a consultant led maternity unit

in the East Midlands
Recruitment from June 1993-May 1994.
Participants
107 nulliparous women using traditional epidural analgesia, set up in the first stage of
labour, maintained by bolus doses of local anaesthetic, and reaching the second stage
without contraindication to spontaneous birth. In most cases the epidural was continued
into the second stage of labour, a passive hour was allowed followed by encouraged
pushing by the midwife
Entry criteria: nulliparity, uncomplicated pregnancy, no history of uterine surgery, live
single cephalic fetus with no abnormality detected, once women in labour at 36 weeks
gestation or greater, with effective epidural analgesia, eligibility was confirmed
Exclusion criteria: breech position, severe pregnancy-induced hypertension, pre-eclampsia or eclampsia, severe intrauterine growth retardation, known intrauterine fetal death,
presence of uterine scar
The proportions of participants in spontaneous or induced labour were not reported.
Use of oxytocin in the second stage was not reported
Interventions
58 were allocated to the supported upright sitting position (normal practice in the unit)
. 6 of these used the lateral position
49 were allocated to use the left or right facing lateral position whichever was most
comfortable. 12 of these used the sitting position
Outcomes
Maternal outcomes
1. Operative birth
4. Trauma to birth canal
13
Downe 2004
(Continued)

6. Duration of second stage labour
7. Maternal experience and satisfaction of labour. Not reported
Baby outcomes
1. Abnormal fetal heart rate patterns, needing intervention. Not reported
2. Apgar scores at 1 and 5 minutes. Not reported
3. Low cord pH not reported
5. Need for ventilation. Not reported.
Notes
Risk of bias
Bias
Authors judgement

bias)
Computer-generated random numbers.
Opaque envelopes stapled to patient notes.

Numbering and sealing not reported
Unclear risk
Blinding (performance bias and detection High risk

bias)
All outcomes
Neither for the patient or the assessor.

All outcomes
Low risk
The main outcomes were reported for all

107 women randomised
Unclear risk
Trial protocol not registered.
Other bias
Unclear risk
Golara 2002
Methods
A randomised controlled trial, conducted in a university teaching hospital in London

The period of recruitment was not recorded.
Participants
Entry criteria: primigravidae, singleton fetus in vertex presentation, 37 weeks or greater,

Continuous spinal epidural catheter sited during the first stage and in situ, achieved full
dilatation, motor function adequate for mobilisation
Exclusion criteria: inadequate motor function, received pethidine 4 hours before full
dilatation
Analgesia was maintained by intermittent bolus injections. A one hour passive phase was
allowed in the second stage
66 (upright = 25, recumbent = 41). 13 (7 recumbent, 6 upright) had induced labour. 8
(4 in each group) were given oxytocin in the second stage
14
Golara 2002
(Continued)
Interventions
25 women allocated to the upright group were asked to spend as much as possible of the
passive phase of the second stage standing or walking. Of these 22 (88%) were upright
for more than 30 minutes
41 women allocated to the recumbent group were asked to be in bed or a chair during
the passive phase. Of these 27 (65%) spent more than 30 minutes in bed, 8 (20%) sat
in a chair for more than 30 minutes and 6 (15%) were walking or standing
Outcomes
Maternal outcomes
1. Operative birth
4. Trauma to birth canal. Recorded as 1st, 2nd or 3rd degree or as episiotomy
6. Duration of second stage labour: unable to be used as it was expressed as median
and range
Baby outcomes
1. Abnormal fetal heart rate patterns
2. Apgar scores at 1 and 5 minutes. not reported
3. Low cord pH defined as less than 7.20
4. Admission to neonatal intensive care unit
5. Need for ventilation. Not reported
Notes
Risk of bias
Bias
Authors judgement

bias)
Computer-generated random numbers. A

copy [of the randomisation sequence] was
kept safe to ensure no violation of randomisation
Sealed brown envelopes. Opacity and numbering not reported.
Unclear risk

bias)
All outcomes

All outcomes
There is a discrepancy in the number of participants reported. The total randomised is

stated to be 70, with 7 post randomisation
withdrawals (i.e. 63 remaining). But the
number reported in the remainder of the
paper is 66
Unclear risk
15
Golara 2002
(Continued)
Unclear risk
Other bias
Unclear risk
Karraz 2003
Methods
A randomised prospective study, in a regional maternity hospital in France

The randomisation ratio was 2:1 ambulatory: recumbent.
Recruitment from February 1999-April 2001.
Participants
Entry criteria: 36-42 weeks pregnant, a singleton pregnancy, cephalic presentation, uncomplicated pregnancies
Exclusion criteria: pre-eclampsia, previous caesarean section
All participants had a low dose ambulatory epidural using intermittent bolus doses (0.
1% ropivacaine and 0.6 micro grams/mL sufentanil) titrated against pain relief
Women in spontaneous (86 ambulatory, 45 non-ambulatory) and induced labour were
included
Use of oxytocin in the second stage was not reported.
221 participants were included. 144 were allocated to the upright position and 77 to
recumbent
Interventions
Women allocated to the ambulatory group were allowed to walk if they had acceptable
analgesia, systolic BP >100 mmHg, and were able to stand on one leg. The number who
walked and the time spent walking were not reported
Women allocated to the non-ambulatory group were not allowed to sit or walk. They
were only allowed to lie supine, semi supine or in a lateral position on the bed. The
number who complied, and the time spent in each position were not reported
Outcomes
Maternal outcomes
1. Operative birth
4. Trauma to birth canal. Not reported
6. Duration of second stage labour: Not reported
Baby outcomes
1. Abnormal fetal heart rate patterns. Not reported
2. Apgar scores at 1 and 5 minutes. not reported no difference at 1 min nor at 5
minutes
3. Low cord pH. not reported
5. Need for ventilation. Not reported
Notes
Risk of bias
16
Karraz 2003
(Continued)
Bias
Authors judgement
Random sequence generation (selection Unclear risk

bias)
Randomly divided into 2 groups. Randomised in 2:1 ratio (upright: recumbent)
Not recorded.
Unclear risk

bias)
All outcomes

All outcomes
Unclear risk
No data reported for 6 post randomisation

exclusions (3 per group)
Unclear risk
Other bias
Unclear risk
Theron 2011
Methods
Randomised controlled trial.

Single centre. University Teaching Hospital.
Participants
Nulliparous women at term. Single fetus. Epidural sited and analgesia established
The type of epidural, and whether it was a walking epidural was not reported
Numbers of spontaneous and induced labours not reported.
Use of oxytocin in the second stage not reported.
Random allocated using computer randomisation.
39 women allocated to sitting. 38 allocated to lateral position
Interventions
Sitting for a 1 hour passive second stage of labour.

Lateral position for 1 hour passive second stage of labour.
Outcomes
Notes
Spontaneous vaginal birth

Instrumental birth
Ventouse birth
Non rotational forceps birth
Rotational forceps birth
Caesarean section
120 patients consented. 43 dropped out after consent.
Risk of bias
Bias
Authors judgement
17
Theron 2011
(Continued)
Random sequence generation (selection Unclear risk

bias)
Computer randomisation.
Not recorded.
Unclear risk
Blinding (performance bias and detection Low risk

bias)
All outcomes
Not blinded. But caesarean and instrumental birth unambiguous endpoints

All outcomes
High risk
43 participants dropped out after consent.

Unclear if this was post randomisation
High risk
Secondary outcomes of maternal acceptability, CTG abnormality and neonatal

outcomes not reported. Trial protocol not
registered
Other bias
Unclear risk
Intended sample size 300. Study stopped

after 77 recruited.
BP: blood pressure

CSE: combined spinal epidural
CTG: cardiotocograph
SD: standard deviation
Characteristics of excluded studies [ordered by study ID]
Study
Reason for exclusion
Asselineau 1996
This was not a randomised trial. Translation from the French indicates that the ambulatory group was
selected by having no contraindications to ambulation and gave consent. The non-ambulatory group was
made up of patients chosen at random from women receiving epidural analgesia
Collis 1999
This trial compared upright versus recumbent in the first stage of labour, The time at which full cervical
dilatation was diagnosed was recorded and all mothers returned to bed
Danilenko-Dixon 1996
The study compared two recumbent positions, supine and lateral
18
Characteristics of ongoing studies [ordered by study ID]

Brocklehurst 2010
Trial name or title
A study of position during the late stages of labour in women with an epidural - BUMPES: a randomised
controlled trial
Methods
Randomised controlled trial.

Anticipated start date: 01/04/2010.
Anticipated end date: 30/04/2015.
Entry criteria: women who are: nulliparous, single cephalic presentation, greater than or equal to 37 weeks
gestation, intend spontaneous vaginal birth, in second stage of labour, with an effective mobile epidural in
situ
Exclusion criteria: unable to understand written and spoken English language
Participants
Target number: 3000.
Interventions
Upright position versus lying-down position throughout the second stage of labour.
Women allocated to an upright position would aim to be in positions where their pelvis is in as vertical a
plane as possible during the second stage of labour.
Women allocated to a lying-down position would aim to be in positions where their pelvis is in as horizontal
a plane as possible during the second stage of labour.
Outcomes
Primary outcome measures: incidence of spontaneous vaginal birth

Secondary outcome measures: mode of birth, outcomes from randomisation until birth, immediate post birth
outcomes, postnatal period for both mother and infant, 1-year outcomes for both mother and infant
Starting date
April 2010.
Contact information
Professor Peter Brocklehurst, Director and Professor of Perinatal Epidemiology

National Perinatal Epidemiology Unit
University of Oxford
Old Road Campus
Headington
Oxford
OX3 7LF
United Kingdom
Telephone: +44 (0)1865 289700
Fax: +44 (0)1865 289701
Email: peter.brocklehurst@npeu.ox.ac.uk
Notes
19
DATA AND ANALYSES
Comparison 1. Upright position versus recumbent position
No. of
studies
No. of
participants
1 Operative birth (Caesarean or

instrumental vaginal)
1.1 Mobile epidurals
1.2 Traditional epidurals or
type not specified
2 Duration of second stage labour
(minutes) (from time of
randomisation to birth)
874
Risk Ratio (M-H, Random, 95% CI)
0.97 [0.76, 1.25]
3
2
690
184

0.87 [0.61, 1.26]

1.14 [0.62, 2.12]
322
Mean Difference (IV, Random, 95% CI)
-22.98 [-99.09, 53.

13]
215

type not specified
3 Instrumental vaginal birth
type not specified
4 Caesarean section
4.2 Tradtional epidurals or
type not specified
5 Trauma to birth canal requiring
suturing
6 Instrumental deliveries for fetal
distress
7 Low cord pH
8 Admission to neonatal intensive
care unit
107
-63.0 [-97.94, -28.

06]
14.70 [-8.14, 37.54]
5
3
2
874
690
184

1.02 [0.81, 1.28]

0.90 [0.72, 1.13]
1.26 [0.79, 2.01]
5
3
2
874
690
184

0.81 [0.38, 1.69]

0.96 [0.40, 2.29]
0.41 [0.11, 1.56]
173
0.95 [0.66, 1.37]
107
1.69 [0.32, 8.84]
1
1
66
66

0.62 [0.18, 2.10]

0.54 [0.02, 12.73]
Outcome or subgroup title
Statistical method
Effect size
20
Analysis 1.1. Comparison 1 Upright position versus recumbent position, Outcome 1 Operative birth
(Caesarean or instrumental vaginal).
Review:
Position in the second stage of labour for women with epidural anaesthesia
Comparison: 1 Upright position versus recumbent position

Outcome: 1 Operative birth (Caesarean or instrumental vaginal)
Study or subgroup
Upright
Recumbent
Risk Ratio
MH,Random,95%
CI
Weight
Risk Ratio
MH,Random,95%
CI
n/N
n/N
112/199
108/210
33.3 %
1.09 [ 0.91, 1.31 ]
Golara 2002
9/25
22/41
12.2 %
0.67 [ 0.37, 1.22 ]
Karraz 2003
24/141
18/74
13.9 %
0.70 [ 0.41, 1.20 ]
365
325
59.4 %
0.87 [ 0.61, 1.26 ]
1 Mobile epidurals
Boyle 2001
Subtotal (95% CI)
Total events: 145 (Upright), 148 (Recumbent)

Heterogeneity: Tau2 = 0.06; Chi2 = 4.47, df = 2 (P = 0.11); I2 =55%
Test for overall effect: Z = 0.73 (P = 0.46)
2 Traditional epidurals or type not specified
Downe 2004
30/58
16/49
16.5 %
1.58 [ 0.99, 2.54 ]
Theron 2011
24/39
27/38
24.2 %
0.87 [ 0.63, 1.19 ]
97
87
40.6 %
1.14 [ 0.62, 2.12 ]
100.0 %
0.97 [ 0.76, 1.25 ]
Subtotal (95% CI)

Total (95% CI)
462
412

Test for subgroup differences: Chi2 = 0.55, df = 1 (P = 0.46), I2 =0.0%
0.01
0.1
Favours experimental
10
100
Favours control
21
Analysis 1.2. Comparison 1 Upright position versus recumbent position, Outcome 2 Duration of second
stage labour (minutes) (from time of randomisation to birth).
Review:

Outcome: 2 Duration of second stage labour (minutes) (from time of randomisation to birth)
Study or subgroup
Upright
Mean
Difference
Recumbent
Mean(SD)
Mean(SD)
141
173 (110)
74
236 (131)
Weight
IV,Random,95% CI
Mean
Difference
IV,Random,95% CI
1 Mobile epidurals
Karraz 2003
Subtotal (95% CI)
141
48.5 %
74
-63.00 [ -97.94, -28.06 ]
48.5 % -63.00 [ -97.94, -28.06 ]
Heterogeneity: not applicable

Downe 2004
Subtotal (95% CI)
58
121 (57.4)
58
49
106.3 (62.2)
51.5 %
14.70 [ -8.14, 37.54 ]
49
51.5 %
14.70 [ -8.14, 37.54 ]
123
100.0 %
-22.98 [ -99.09, 53.13 ]

Total (95% CI)
199

Test for subgroup differences: Chi2 = 13.31, df = 1 (P = 0.00), I2 =92%
-100
-50
Favours Upright
50
100
Favours Recumbent
22
Analysis 1.3. Comparison 1 Upright position versus recumbent position, Outcome 3 Instrumental vaginal
birth.
Review:

Outcome: 3 Instrumental vaginal birth
Study or subgroup
Upright
Recumbent
Risk Ratio
MH,Random,95%
CI
Weight
Risk Ratio
MH,Random,95%
CI
n/N
n/N
73/199
82/210
41.1 %
0.94 [ 0.73, 1.20 ]
Golara 2002
9/25
21/41
12.5 %
0.70 [ 0.38, 1.28 ]
Karraz 2003
11/141
6/74
5.5 %
0.96 [ 0.37, 2.50 ]
365
325
59.1 %
0.90 [ 0.72, 1.13 ]
1 Mobile epidurals
Boyle 2001
Subtotal (95% CI)

Heterogeneity: Tau2 = 0.0; Chi2 = 0.78, df = 2 (P = 0.68); I2 =0.0%
Downe 2004
29/58
15/49
17.2 %
1.63 [ 1.00, 2.68 ]
Theron 2011
22/39
21/38
23.7 %
1.02 [ 0.69, 1.52 ]
97
87
40.9 %
1.26 [ 0.79, 2.01 ]
100.0 %
1.02 [ 0.81, 1.28 ]
Subtotal (95% CI)

Total (95% CI)
462
412

0.01
0.1
Favours Upright
10
100
Favours Recumbent
23
Analysis 1.4. Comparison 1 Upright position versus recumbent position, Outcome 4 Caesarean section.
Review:

Outcome: 4 Caesarean section
Study or subgroup
Upright
Recumbent
Risk Ratio
MH,Random,95%
CI
Weight
Risk Ratio
MH,Random,95%
CI
n/N
n/N
39/199
26/210
40.5 %
1.58 [ 1.00, 2.50 ]
Golara 2002
0/25
1/41
4.9 %
0.54 [ 0.02, 12.73 ]
Karraz 2003
13/141
12/74
32.6 %
0.57 [ 0.27, 1.18 ]
365
325
78.0 %
0.96 [ 0.40, 2.29 ]
1 Mobile epidurals
Boyle 2001
Subtotal (95% CI)

2 Tradtional epidurals or type not specified
Downe 2004
1/58
1/49
6.3 %
0.84 [ 0.05, 13.16 ]
Theron 2011
2/39
6/38
15.7 %
0.32 [ 0.07, 1.51 ]
97
87
22.0 %
0.41 [ 0.11, 1.56 ]
100.0 %
0.81 [ 0.38, 1.69 ]
Subtotal (95% CI)

Heterogeneity: Tau2 = 0.0; Chi2 = 0.35, df = 1 (P = 0.55); I2 =0.0%
Total (95% CI)
462
412

0.01
0.1
Favours Upright
10
100
Favours Recumbent
24
Analysis 1.5. Comparison 1 Upright position versus recumbent position, Outcome 5 Trauma to birth canal
requiring suturing.
Review:

Outcome: 5 Trauma to birth canal requiring suturing
Study or subgroup
Upright
Recumbent
n/N
n/N
Downe 2004
50/58
38/49
56.7 %
1.11 [ 0.93, 1.33 ]
Golara 2002
16/25
34/41
43.3 %
0.77 [ 0.56, 1.07 ]
83
90
100.0 %
0.95 [ 0.66, 1.37 ]
Total (95% CI)
Risk Ratio
MH,Random,95%
CI
Weight
Risk Ratio
MH,Random,95%
CI

Test for subgroup differences: Not applicable
0.01
0.1
Favours Upright
10
100
Favours Recumbent
Analysis 1.6. Comparison 1 Upright position versus recumbent position, Outcome 6 Instrumental
deliveries for fetal distress.
Review:

Outcome: 6 Instrumental deliveries for fetal distress
Study or subgroup
Upright
Recumbent
Risk Ratio
MH,Random,95%
CI
Weight
Risk Ratio
MH,Random,95%
CI
n/N
n/N
Downe 2004
4/58
2/49
100.0 %
1.69 [ 0.32, 8.84 ]
Total (95% CI)
58
49
100.0 %
1.69 [ 0.32, 8.84 ]

0.01
0.1
Favours Upright
10
100
Favours Recumbent
25
Analysis 1.7. Comparison 1 Upright position versus recumbent position, Outcome 7 Low cord pH.
Review:

Outcome: 7 Low cord pH
Study or subgroup
Golara 2002
Total (95% CI)
Upright
Recumbent
Risk Ratio
MH,Random,95%
CI
Weight
Risk Ratio
MH,Random,95%
CI
n/N
n/N
3/25
8/41
100.0 %
0.62 [ 0.18, 2.10 ]
25
41
100.0 %
0.62 [ 0.18, 2.10 ]

0.01
0.1
Favours Upright
10
100
Favours Recumbent
26
Analysis 1.8. Comparison 1 Upright position versus recumbent position, Outcome 8 Admission to neonatal
intensive care unit.
Review:

Outcome: 8 Admission to neonatal intensive care unit
Study or subgroup
Golara 2002
Total (95% CI)
Upright
Recumbent
Risk Ratio
MH,Random,95%
CI
Weight
Risk Ratio
MH,Random,95%
CI
n/N
n/N
0/25
1/41
100.0 %
0.54 [ 0.02, 12.73 ]
25
41
100.0 %
0.54 [ 0.02, 12.73 ]

0.01
0.1
Favours Upright
10
100
Favours Recumbent
CONTRIBUTIONS OF AUTHORS
Marion Kibuka designed and wrote the first version of the protocol. Claire Kingswood revised the protocol. Jim Thornton revised the
protocol. Emily Kemp and Jim Thornton identified, and classified studies, abstracted and entered data, carried out the analysis and
wrote the review.
DECLARATIONS OF INTEREST
None known.
SOURCES OF SUPPORT
Internal sources
University of Nottingham, UK.
Claire Kingswood and Emily Kemp worked on this review as part of their BMedSci projects in 2009 and 2010
27
External sources
No sources of support supplied
DIFFERENCES BETWEEN PROTOCOL AND REVIEW

The methods have been updated in accordance with the latest Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).
INDEX TERMS
Medical Subject Headings (MeSH)
Analgesia, Epidural [ methods]; Analgesia, Obstetrical [ methods]; Cesarean Section; Extraction, Obstetrical [methods]; Labor Stage,
Second [ physiology]; Patient Positioning [ methods]; Posture [ physiology]; Randomized Controlled Trials as Topic
MeSH check words

Female; Humans; Pregnancy
28

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Position in the second stage of labour for women with

epidural anaesthesia (Review)

Position in the second stage of labour for women with

PLAIN LANGUAGE SUMMARY

prolonged labour (Lieberman 2005; Martino 2007). Secondly,

during labour (COMET 2001).

Criteria for considering studies for this review

sitting (on a bed);

Search methods for identification of studies

within the editorial information about the Cochrane Pregnancy

Data collection and analysis

unclear risk of bias.

(2) Allocation concealment (checking for possible selection

We described for each included study the method used to conceal

Data extraction and management

(1) Sequence generation (checking for possible selection

We described for each included study the method used to generate

(3) Blinding (checking for possible performance bias)

We described for each included study the methods used, if any, to

(4) Incomplete outcome data (checking for possible attrition

We described for each included study, and for each outcome or

(5) Selective reporting bias

Dealing with missing data

We described for each included study how we investigated the

For included studies, we noted levels of attrition. We explored the

(6) Other sources of bias

We described for each included study any important concerns we

(7) Overall risk of bias

We make explicit judgements about whether studies are at high risk

Measures of treatment effect

For dichotomous data, we present results as summary risk ratio

Subgroup analysis and investigation of heterogeneity

For continuous data, we used the mean difference if outcomes

We planned to carry out the following subgroup analyses.

See: Characteristics of included studies; Characteristics of excluded

Five studies, involving 879 women, were included in the review,

Results of the search

Risk of bias in included studies

Other potential sources of bias

In none of the studies were the patient or the assessor masked to

Incomplete outcome data

Summary of main results

Overall completeness and applicability of

Quality of the evidence

epidural should be encouraged to use whatever position they find

Potential biases in the review process

Agreements and disagreements with other

Implications for research

References to studies included in this review

Golara M, Shennan AH. Upright versus recumbent

References to studies excluded from this review

deambulation sous peridurale lors du travail modifietelle

References to ongoing studies

Indicates the major publication for the study

Characteristics of included studies [ordered by study ID]

A randomised controlled trial in a consultant maternity unit in Hertfordshire

Random sequence generation (selection Low risk

Support for judgement

Allocation concealment (selection bias)

Randomisation was achieved by the use

Blinding (performance bias and detection Low risk

The trial was unavoidably unblinded, but

Incomplete outcome data (attrition bias)

No losses to follow-up recorded and only