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Cochrane Database of Systematic Reviews

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

This is not the most recent version

view the current version 09 November 2018

Information

DOI:
https://doi.org/10.1002/14651858.CD008070.pub3Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 24 February 2017see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:

  1. Cochrane Pregnancy and Childbirth Group

Copyright:
  1. Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Marion Kibuka

    Maternity, East Kent Hospitals University NHS Foundation Trust, Canterbury, UK

  • Jim G Thornton

    Correspondence to: Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK

    [email protected]

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 initial version of this review.

For this update, Marion Kikbuka assessed the studies. Jim Thornton reviewed the final version. Also see Acknowledgements in relation to the assistance we received from Anna Cuthbert.

Sources of support

Internal sources

  • University of Nottingham, UK.

    Claire Kingswood and Emily Kemp worked on the 2013 version of this review as part of their BMedSci projects in 2009 and 2010

External sources

  • UNDP‐UNFPA‐UNICEF‐WHO‐World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research (RHR), World Health Organization, Switzerland.

Declarations of interest

Marion Kibuka: none known

Jim G Thornton: none known.

Acknowledgements

We are grateful to Emily Kemp and Claire J Kingswood for their contribution to the initial version of this review (Kemp 2013).

We would also like to thank Bita Mesgarpour for translating and assessing Amiri 2012.

This project was supported by the National Institute for Health research, via Cochrane Infrastructure funding to Cochrane Pregnancy and Childbirth. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS or the Department of Health.

We are grateful to Anna Cuthbert (Research Associate with Cochrane Pregnancy and Childbirth) for her help in preparing this 'no new studies' update. Anna assessed studies for inclusion and prepared the updated review.

Version history

Published

Title

Stage

Authors

Version

2018 Nov 09

Maternal position in the second stage of labour for women with epidural anaesthesia

Review

Kate F Walker, Marion Kibuka, Jim G Thornton, Nia W Jones

https://doi.org/10.1002/14651858.CD008070.pub4

2017 Feb 24

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

Review

Marion Kibuka, Jim G Thornton

https://doi.org/10.1002/14651858.CD008070.pub3

2013 Jan 31

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

Review

Emily Kemp, Claire J Kingswood, Marion Kibuka, Jim G Thornton

https://doi.org/10.1002/14651858.CD008070.pub2

2009 Oct 07

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

Protocol

Marion Kibuka, Jim G Thornton, Claire J Kingswood

https://doi.org/10.1002/14651858.CD008070

Differences between protocol and review

The methods have been updated and the current standard methods text for Cochrane Pregnancy and Childbirth has been incorporated. This includes the use of GRADE and inclusion of a 'Summary of findings' table. We have restructured the Plain Language Summary using the standardised headings developed by Cochrane Pregnancy and Childbirth.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Female; Humans; Pregnancy;

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Study flow diagram
Figures and Tables -
Figure 1

Study flow diagram

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study
Figures and Tables -
Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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Comparison 1 Upright position versus recumbent position, Outcome 1 Operative birth (caesarean or instrumental vaginal).
Figures and Tables -
Analysis 1.1

Comparison 1 Upright position versus recumbent position, Outcome 1 Operative birth (caesarean or instrumental vaginal).

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Comparison 1 Upright position versus recumbent position, Outcome 2 Duration of second stage labour (minutes) (from time of randomisation to birth).
Figures and Tables -
Analysis 1.2

Comparison 1 Upright position versus recumbent position, Outcome 2 Duration of second stage labour (minutes) (from time of randomisation to birth).

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Comparison 1 Upright position versus recumbent position, Outcome 3 Caesarean section.
Figures and Tables -
Analysis 1.3

Comparison 1 Upright position versus recumbent position, Outcome 3 Caesarean section.

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Comparison 1 Upright position versus recumbent position, Outcome 4 Instrumental vaginal birth.
Figures and Tables -
Analysis 1.4

Comparison 1 Upright position versus recumbent position, Outcome 4 Instrumental vaginal birth.

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Comparison 1 Upright position versus recumbent position, Outcome 5 Trauma to birth canal requiring suturing.
Figures and Tables -
Analysis 1.5

Comparison 1 Upright position versus recumbent position, Outcome 5 Trauma to birth canal requiring suturing.

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Comparison 1 Upright position versus recumbent position, Outcome 6 Abnormal fetal heart rate patterns, requiring intervention.
Figures and Tables -
Analysis 1.6

Comparison 1 Upright position versus recumbent position, Outcome 6 Abnormal fetal heart rate patterns, requiring intervention.

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Comparison 1 Upright position versus recumbent position, Outcome 7 Low cord pH.
Figures and Tables -
Analysis 1.7

Comparison 1 Upright position versus recumbent position, Outcome 7 Low cord pH.

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Comparison 1 Upright position versus recumbent position, Outcome 8 Admission to neonatal intensive care unit.
Figures and Tables -
Analysis 1.8

Comparison 1 Upright position versus recumbent position, Outcome 8 Admission to neonatal intensive care unit.

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Summary of findings for the main comparison. Upright position compared to recumbent position for the second stage of labour for women with epidural anaesthesia

Upright position compared to recumbent position for the second stage of labour for women with epidural anaesthesia

Patient or population: women with epidural anaesthesia in the second stage of labour
Setting: hospitals in France (1 study) and the UK (4 studies)
Intervention: upright position
Comparison: recumbent position

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with recumbent position

Risk with upright position

Operative birth (caesarean or instrumental vaginal)

Study population

RR 0.97
(0.76 to 1.25)

874
(5 RCTs)

⊕⊕⊕⊝
Moderate1,2

464 per 1000

450 per 1000
(352 to 579)

Duration of second stage labour (minutes) (from time of randomisation to birth)

The mean duration of second stage labour was 22.98 minutes less for women in the upright position (99.09 minutes less to 53.13 minutes more)

322
(2 RCTs)

⊕⊝⊝⊝
Very low3,4

Trauma to birth canal requiring suturing

Study population

RR 0.95
(0.66 to 1.37)

173
(2 RCTs)

⊕⊝⊝⊝
Very low4,5,6

800 per 1000

760 per 1000
(528 to 1000)

Blood loss (greater than 500 mL) (or as defined by trial authors)

Study population

‐

(0 studies)

‐

No trial reported this outcome

see comment

see comment

Abnormal fetal heart rate patterns, requiring intervention

Study population

RR 1.69
(0.32 to 8.84)

107
(1 RCT)

⊕⊝⊝⊝
Very low7,8

41 per 1000

69 per 1000
(13 to 361)

Low cord pH less than 7.1 (or as defined by trial authors)

Study population

RR 0.61
(0.18 to 2.10)

66
(1 RCT)

⊕⊝⊝⊝
Very low7,8

195 per 1000

119 per 1000
(35 to 410)

Admission to neonatal intensive care unit

Study population

RR 0.54
(0.02 to 12.73)

66
(1 RCT)

⊕⊝⊝⊝
Very low7,8

24 per 1000

13 per 1000
(0 to 310)

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; RR: Risk ratio

GRADE Working Group grades of evidence
High quality: we are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect
Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect

1All studies had design limitations. One trial contributing 24.2% weight had serious design limitations (‐1).
2Heterogeneity, I2 = 54% (not downgraded).
3Severe heterogeneity, I2 = 92% (‐1).
4Small sample size and very wide confidence intervals that cross the line of no effect (‐2).
5Both studies contributing data had design limitations (‐1).
6High heterogeneity, I2 = 74% (‐1).
7One study with design limitations. (‐1).
8Very small sample size, few events and wide confidence intervals that cross the line of no effect (‐2).

Figures and Tables -
Summary of findings for the main comparison. Upright position compared to recumbent position for the second stage of labour for women with epidural anaesthesia
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Comparison 1. Upright position versus recumbent position

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Operative birth (caesarean or instrumental vaginal) Show forest plot

5

874

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.76, 1.25]

1.1 "Mobile" epidurals

3

690

Risk Ratio (M‐H, Random, 95% CI)

0.87 [0.61, 1.26]

1.2 Traditional epidurals or type not specified

2

184

Risk Ratio (M‐H, Random, 95% CI)

1.14 [0.62, 2.12]

2 Duration of second stage labour (minutes) (from time of randomisation to birth) Show forest plot

2

322

Mean Difference (IV, Random, 95% CI)

‐22.98 [‐99.09, 53.13]

2.1 "Mobile" epidurals

1

215

Mean Difference (IV, Random, 95% CI)

‐63.0 [‐97.94, ‐28.06]

2.2 Traditional epidurals or type not specified

1

107

Mean Difference (IV, Random, 95% CI)

14.70 [‐8.14, 37.54]

3 Caesarean section Show forest plot

5

874

Risk Ratio (M‐H, Random, 95% CI)

0.81 [0.38, 1.69]

3.1 "Mobile" epidurals

3

690

Risk Ratio (M‐H, Random, 95% CI)

0.96 [0.40, 2.29]

3.2 Tradtional epidurals or type not specified

2

184

Risk Ratio (M‐H, Random, 95% CI)

0.41 [0.11, 1.56]

4 Instrumental vaginal birth Show forest plot

5

874

Risk Ratio (M‐H, Random, 95% CI)

1.02 [0.81, 1.28]

4.1 "Mobile" epidurals

3

690

Risk Ratio (M‐H, Random, 95% CI)

0.90 [0.72, 1.13]

4.2 Traditional epidurals or type not specified

2

184

Risk Ratio (M‐H, Random, 95% CI)

1.26 [0.79, 2.01]

5 Trauma to birth canal requiring suturing Show forest plot

2

173

Risk Ratio (M‐H, Random, 95% CI)

0.95 [0.66, 1.37]

6 Abnormal fetal heart rate patterns, requiring intervention Show forest plot

1

107

Risk Ratio (M‐H, Random, 95% CI)

1.69 [0.32, 8.84]

7 Low cord pH Show forest plot

1

66

Risk Ratio (M‐H, Random, 95% CI)

0.62 [0.18, 2.10]

8 Admission to neonatal intensive care unit Show forest plot

1

66

Risk Ratio (M‐H, Random, 95% CI)

0.54 [0.02, 12.73]
Figures and Tables -
Comparison 1. Upright position versus recumbent position
Navigate to table in Review