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

Kemp E, Kingswood CJ, Kibuka M, Thornton JG. Position in the second stage of labour for women with epidural anaesthesia. Cochrane Database Syst Rev. 2013 Jan 31;(1):CD008070. doi: 10.1002/14651858.CD008070.pub2. Review. Update in: Cochrane Database Syst Rev. 2017 Feb 24;2:CD008070. PubMed PMID: 23440824.

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 Group’s 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.

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