Methods

Randomised trial: using a convenience sample over a 3‐month period.

Participants

40 women, Cleveland, U.S.A.

• 20 study participants: nulliparous

• 20 control participants nulliparous

Inclusion Criteria:

Parity: nulliparous,

Pluralty: single vertex fetus in an anterior position,

Gestation: 38 to 42 weeks

Onset of labour: spontaneous

Other: medically uncomplicated pregnancies; adequate pelvic measurements; intact amniotic membranes at the beginning of the maximum slope in their labour (4 to 9 cm dilatation).

Interventions

Study group:

• 20 women ‐ upright: standing, ambulating, sitting, squatting, or kneeling.

15 women chose to lie down after receiving medication for rest: 5 of these women immediately returned to the upright position, stating that the contractions were more painful when they were lying down. The remaining 10 chose the lateral position to rest for up to 1 hour during the study period.

Control group:

• 20 women ‐ recumbent: supine, lateral, or prone ‐ hands and knees.

All women:

‐ position assumed when cervical dilatation was from 4 to 9 cm,

‐ were free to choose several variations within each position group.
‐ were free to assume positions from the other group for routines of care or rest, these activities were documented.

Outcomes

Maternal Outcomes:

1. Duration of first stage of labour.

2. Maternal Comfort.

3. Analgesia amount.

Neonatal Outcomes:

Nil

Notes

1. The length of maximum slope in labour was recorded. This is a subdivision of the first stage of labour, during which rapid cervical dilatation takes place (from 4 to 9 cm). The duration of the first stage was determined by the first recorded time that cervical dilatation was assessed to be 4 cm and on the first recorded time that dilatation was assessed to be 9 cm.

2. The Maternal Comfort Assessment Tool was used. The tool estimates the level of maternal comfort by measuring focus of attention; eye contact during contractions; breathing pattern and vocal behaviour during contractions; muscle tension and activity during contractions; and verbalisations regarding ability to continue with labour. In addition, vital signs; degree of cervical dilatation; duration, frequency, and intensity of contractions; medications; and use of monitoring apparatus were recorded. When the scores for each category of observable behaviour in the tool are added, the highest possible comfort score for each contraction was 14 and the lowest was 0. Comfort scores for a series of 3 contractions were recorded on an hourly basis during the phase of maximum slope, and averaged for mean hourly comfort scores. Hourly comfort scores where then average to obtain an overall mean comfort score for each woman.

3. The amount of narcotic and other analgesia.

The randomisation method is unclear.

Women in the recumbent position were monitored externally more often (n = 13) than women in the upright position (n = 1), which may have been an additional source of discomfort for women in the recumbent group.

Apgar scores were not included as outcome measures because only a mean Apgar at 1 minute for each group was provided.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Described as 'randomly assigned'.

Allocation concealment (selection bias)

Unclear risk

Not stated.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No stated losses to follow‐up.

Selective reporting (reporting bias)

Unclear risk

Unclear.

Methods

Randomised trial

Participants

200 women, Sousse, Tunisia.

• 100 study participants: nulliparous

• 100 control participants: nulliparous

Inclusion Criteria:

Parity: nulliparous,

Pluralty: singleton,

Gestation: term,

Onset of labour: spontaneous

Other: less than 4 cm dilatation; cephalic presentation; no pathological antecedents; absence of fetal compromise; normal maternal examination; eligible for vaginal birth; consenting to participate.

Interventions

Study group:

• 100 women ‐ authorised to ambulate until 6 cm of cervical dilatation.

Control group:

• 100 women ‐ confined to bed in dorsal or lateral recumbence

Outcomes

Maternal Outcomes:

1. Duration of first stage labour.

2. Mode of birth.

3. Maternal pain.

4. Duration of second stage labour.

5. Estimated blood loss > 500 mL.

6. Perineal trauma.

Neonatal Outcomes:

1. Admission to NICU

Notes

1. Duration of first stage of labour: no standard deviation reported. Standard deviation calculated using the weighted average standard deviation reported for nulliparous women.

Unable to extract data for oxytocic use or Apgar scores ‐ only mean scores provided.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Not stated.

Allocation concealment (selection bias)

Low risk

Sequentially numbered sealed envelopes.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No stated losses to follow‐up.

Selective reporting (reporting bias)

Unclear risk

Unclear.

Methods

Randomised trial: over a 12‐month period.

Participants

1067 women, Dallas, U.S.A.

• 536 study participants: 272 primigravidae, 264 multigravida

• 531 control participants: 272 primigravidae, 259 multigravida

Inclusion Criteria:

Parity: mixed,

Pluralty: not stated,

Gestation: between 36 and 41 weeks,

Onset of labour: spontaneous,

Other: cervical dilatation of 3 to 5 cm; in active labour; fetuses in cephalic presentation; uncomplicated pregnancies.

Interventions

Study group:

• 536 women assigned to walking (walking as desired).

Women were encouraged to walk but were instructed to return to their beds when they needed intravenous or epidural analgesia or when the second stage of labour began.

Nurses recorded the number of minutes spent walking.

If continuous electronic fetal heart rate monitoring was required, further walking was prohibited.

Of the 536 women assigned to the walking group: 380 actually walked; 30 had incomplete walking records; 8 had advanced cervical dilatation at the time of randomisation; and 2 had a fetus with unrecognised breech presentation.

Control group:

• 531 women assigned to labour in bed (usual care ‐ confined to a labour bed).

Women were permitted to assume their choice of supine, lateral or sitting positions during labour.

All women:

‐ routine surveillance using handheld a Doppler device was conducted every 30 mins.
‐ continuous electronic fetal heart rate monitoring was used for: fetal heart‐rate abnormalities; meconium in the amniotic fluid; women in whom labour was augmented by the administration of oxytocin.
‐ pelvic examinations were performed approximately every 3 hours: ineffective labour was suspected if the cervix did not dilate progressively during the first two hours after admission.

‐ amniotomy was performed if the fetal membranes were intact,

‐ labour was augmented by intravenous oxytocin (initial dose 6 mU per min, increased every 40 mins by 6 mU per min to a maximum of 42 mU per min if a woman had hypotonic uterine contractions, and no further cervical dilatation after an additional 2‐3 hours.

‐ Dystocia was diagnosed if labour had not progressed in 2‐4 hours.
‐ positions permitted during birth included the lateral (Sims') position and the dorsal‐lithotomy position, with or without obstetrical stirrups.

‐ all women wore pedometers

Outcomes

Maternal Outcomes:

1. Duration of first stage of labour.

2. Mode of birth.

3. Maternal pain.

4. Analgesia type.

5. Duration of second stage of labour.

6. Augmentation of labour using oxytocin.

7. Perineal trauma.

Neonatal Outcomes:

1. Fetal distress.

2. Use of neonatal mechanical ventilation.

3. Apgar scores.

4. Perinatal mortality.

Notes

Limitations of the protocol: inability to mask walking; inability to extrapolate results to women with pregnancy complications, higher rates of caesarean birth or epidural analgesia; lack of objective methods to gauge maternal satisfaction with either walking or lying down during labour.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Described as 'randomly assigned'.

Allocation concealment (selection bias)

Unclear risk

Not stated.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No stated losses to follow‐up.

Selective reporting (reporting bias)

Unclear risk

Unclear

Methods

Randomisation was achieved by the use of sequentially numbered sealed envelopes. A computer‐generated random number sequence was used.

Participants

409 women, Hertfordshire, U.K.

• 199 study participants:145 primigravidae, 54 multigravida

• 210 control participants:151 primigravidae, 59 multigravida

Inclusion Criteria:

Parity: mixed,

Pluralty: not stated,

Gestation: greater than 34 weeks,

Onset of labour: spontaneous and induction of labour,

Other: cervical dilatation of 3 to 5 cm; in active labour; fetuses in cephalic presentation; uncomplicated pregnancies; women who chose to use a CSE between August 1st 1999 to December 31st 2000.

Exclusion Criteria: women who were physically unable to ambulate or could not understand English.

Interventions

Study group:

• 199 women were assigned to the ambulant group

Women in the experimental group were encouraged to ambulate for at least 15 mins in each hour.

Midwives used a modified Bromage scale in order to assess maternal mobility after the CSE had been cited and prior to ambulation.

The mean time of ambulation in the ambulant group was only 8.74 to 9.55 mins.

69 out of 199 women (34%) underwent induction of labour.

Control group:

• 210 women were assigned to the non‐ambulant group

Women in the control group received normal care in labour.

51 out of 210 (24%) women underwent induction of labour.

All women:

‐ pain was assessed with a visual analogue pain score.

Outcomes

Maternal Outcomes:

1. Mode of Birth

2. Analgesia Amount

Neonatal Outcomes:

Nil

Notes

No durations of labour times, but author stated "there was no difference".

Mode of birth data totals differ from demographic data totals.

Apgar scores reported as means, therefore unable to be used.

Pooled data used from nulliparous and multiparous total dose of analgesia.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Computer‐generated random number sequence.

Allocation concealment (selection bias)

Low risk

Sequentially numbered sealed envelopes.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No stated losses to follow‐up.

Selective reporting (reporting bias)

Unclear risk

Unclear.

Methods

Randomised trial of women undergoing induction of labour.

Participants

60 women, Goteborg, Sweden.

• 40 study participants: mixed parity

• 20 control participants: mixed parity

Inclusion Criteria:

Parity: mixed,

Pluralty: not stated,

Gestation: not stated,

Onset of labour: induced,

Other: nil stated.

Interventions

Study group:

• 40 women were assigned to ambulation (telemetry).

20 women were assigned to receive telemetry and transcutaneous electrical nerve stimulation (TNS), and 20 women were assigned to receive telemetry without TNS.

Control group:

• 20 women were assigned to bed care, with conventional monitoring in bed.

All women:

‐ primary amniotomy,

‐ internal monitoring.

Outcomes

Maternal Outcomes:

1. Mode of birth.

2. Artificial rupture of membranes

Neonatal Outcomes:

Nil

Notes

Insufficient data to include total duration of labour (reported as 8 hours for primiparae and 4 hours for multipara in the study group; and 10 hours for primiparae and 6 hours for multipara in the control group).

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Described as 'randomisation to three groups'.

Allocation concealment (selection bias)

Unclear risk

Not stated

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

No stated losses to follow‐up.

Selective reporting (reporting bias)

High risk

Claimed evidence of an outcome with little or no data to support it.

Methods

Quasi‐randomised trial. Patients were randomly allocated based on whether the final digit of their hospital number was odd or even.

Participants

200 women, Cardiff, U.K.

• 100 study participants: 56 primigravidae, 44 multigravida

• 100 control participants: 50 primigravidae, 50 multigravida

Inclusion Criteria:

Parity: mixed,

Pluralty: singleton,

Gestation: term (at least 37 weeks' gestation),

Onset of labour: spontaneous,

Other: vertex presentation; uterine contractions occurring at least every 10 mins; cervix at least 2.5 cm dilated; no contraindication to vaginal birth.

Exclusion criteria ‐ women who had previously suffered a stillbirth or neonatal death or who had undergone a caesarean birth.

Interventions

Study group:

• 100 women were assigned to telemetry

Women were advised that they could get of bed to walk, sit in an easy chair or use the day room.

Only 45 women actually got out of bed. They remained out of bed between 3 mins, and 4 hours and 20 mins. The average time out of bed was 1 hour and 44 mins. 34 of those who left their beds initially, elected to stay in bed by the time they reached a cervical dilatation of 7 cm.

Control group:

• 100 women were assigned to bed care and conventional bedside cardiotocography.

All patients in bed were nursed in the lateral position or with a lateral tilt.

Outcomes

Maternal Outcomes:

1. Duration of first stage of labour.

2. Mode of birth.

3. Maternal pain.

4. Maternal anxiety.

5. Analgesia type.

6. Duration of second stage.

Neonatal Outcomes:

1. Apgar scores.

Notes

3. Within 24 hours of birth all patients were asked to complete a questionnaire to express their experience of pain, anxiety, comfort and restriction of mobility during the first stage of labour and the degree of induced anxiety or reassurance attributed to the monitor. Assessment was based on linear analogue scales. A score of 0 indicated nil and the score 100 indicated the maximum imaginable.

5. Duration of second stage only given for those who delivered spontaneously.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

High risk

Described as 'Final digit of hospital number (odd or even)'.

Allocation concealment (selection bias)

High risk

Described as 'Final digit of hospital number (odd or even)'.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No stated losses to follow‐up.

Selective reporting (reporting bias)

Unclear risk

Unclear.

Methods

Quasi‐randomised trial.

Participants

200 women, Hong Kong.

• 100 study participants: primigravidae.

• 100 control participants: primigravidae.

Inclusion Criteria:

Parity: primigravidae,

Pluralty: not stated,

Gestation: not stated,

Onset of labour: not stated,

Other: nil stated.

Exclusion criteria ‐ planned elective caesarean birth.

Interventions

Study group:

• 100 women were kept in the erect position (sit or walk).

Control group:

• 100 women were kept in a supine or lateral position.

Outcomes

Maternal Outcomes:

1. Duration of first stage of labour.

2. Mode of birth.

3. Maternal pain.

4. Analgesia type.

5. Duration of second stage of labour.

Neonatal Outcomes:

1. Fetal distress.

2. Perinatal mortality.

Notes

1. Duration of first stage of labour: no standard deviation or P values reported. Standard deviation calculated using the weighted average standard deviation reported for nulliparous women. Summary totals exclude number of L.S.C.S. cases.

2. Assisted breech births (2 upright, 4 recumbent) not included in spontaneous vaginal, operative vaginal or caesarean birth summary totals.

5. Duration of second stage of labour: no standard deviation or P values reported. Standard deviation calculated using the weighted average standard deviation reported. Summary totals exclude number of L.S.C.S. cases.

6. The summary total included one set of twins.

7. The summary total included one set of twins.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

High risk

Alternate group allocation.

Allocation concealment (selection bias)

High risk

Not stated.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

No stated losses to follow‐up.

Selective reporting (reporting bias)

Unclear risk

Unclear.

Methods

Quasi‐randomised trial: over a 2.5 year period.

Participants

185 women, Oita, Japan.

• 61 study participants: 33 primigravidae, 28 multigravida

• 124 control participants: 68 primigravidae, 56 multigravida

Inclusion Criteria:

Parity: mixed,

Pluralty: singleton,

Gestation: full term,

Onset of labour: spontaneous,

Other: cephalic presentation; uneventful pregnancies.

Exclusion criteria ‐ women received oxytocin augmentation; caesarean birth due to cephalo‐pelvic disproportion or fetal distress; women requested and received epidural anaesthesia; child with congenital anomalies; tococardiogram records were unsuitable for reading (n = 67 exclusions after group allocation).

Interventions

Study group:

• 41 women were free to assume any comfortable position in home‐like part of obstetric unit (furnished with desk, chair, sofa but no bed)(sitting) .

Most sat on a sofa (back of sofa at 65 degree angle from horizontal) with their knees flexed. When each woman's cervix became fully dilated, she was transferred to a birthing chair.

There were 20 post‐randomisation exclusions from the study group. Reasons for exclusion included: oxytocin augmentation (n = 2); caesarean birth due to CPD (n = 2); caesarean birth due to fetal distress (n=3); epidural anaesthesia (n = 3); fetal anomaly (n = 1); unsatisfactory TCG record (n = 9).

Control group:

• 75 women were assigned to maintain a dorsal or lateral recumbent position (supine): 32 women were assigned to a supine position in the first stage of labour and the birthing chair in the second stage of labour; 43 women were allocated to maintain a supine position throughout labour.

There were 49 post‐randomisation exclusions from the control group: Reasons for exclusion included: oxytocin augmentation (n = 13); caesarean birth due to CPD (n = 8); caesarean birth due to fetal distress (n = 2); epidural anaesthesia (n = 9); fetal anomaly (n = 3); unsatisfactory TCG record (n = 14).

All women:

‐ no analgesia or anaesthesia was used except for pudendal nerve block or perineal infiltration of xylocaine.

‐ amniotomy was performed when cervical dilatation reached 3 to 4 cm.

Outcomes

Maternal Outcomes:

1. Duration of first stage of labour.

2. Mode of birth.

3. Analgesia type.

4. Duration of second stage of labour.

5. Augmentation of labour using oxytocin.

6. Artificial rupture of membranes.

Neonatal Outcomes:

1. Fetal distress requiring immediate birth.

Notes

1. Duration recorded from 5 to 10 cm dilation only.

Pooled data used from nulliparous and multiparous durations of first stage labour.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

High risk

Described as 'Allocated following the order of their admission into the study'.

Allocation concealment (selection bias)

High risk

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

High risk

67 participants were excluded after group allocation (37%). Some of the reasons for exclusion are unlikely to have related to the intervention (e.g. children born with congenital abnormalities) but other reasons may have related to group allocation (e.g. oxytocin augmentation, caesarean for fetal distress).

Selective reporting (reporting bias)

Unclear risk

Unclear

Methods

Randomised trial of women receiving a CSE

Participants

229 women, London, U.K.

• 110 study participants: nulliparous

• 119 control participants: nulliparous

Inclusion Criteria:

Parity: nulliparous,

Pluralty: singleton,

Gestation: 36 to 42 weeks,

Onset of labour: spontaneous or induced,

Other: cephalic presentation; requested regional analgesia (given CSE); no other pregnancy complications.

Interventions

Study group:

• 110 women were encouraged to spend at least 20 mins of each hour out of bed ‐ walking, standing, sitting in a rocking chair.

51 women achieved at least 30% of time out of bed, 15 women spent no time out of bed, 44 spent 1 to 29%, 32 spent 30% to 59% and 19 women spent > 60% of time out of bed.

Reasons for not ambulating: 16 women developed motor block, 25 mothers were fatigued, 10 women were following instructions of the midwife.

Control group:

• 119 women were encouraged to stay in bed ‐ sitting up in bed or lying on either side.

16 women got out of bed: 15 between 1% to 29% of the time and 1 between 30% to 59% of the time.
Reasons for ambulating: to pass urine.

All women:

‐ continuous fetal monitoring,
‐ 500‐1000 mL Hartmann's solution infused as a preload,

‐ CSE ‐ 27‐G Becton‐Dickinson Whitacre 119 mm spinal needle and 16‐G Tuohy needle'

‐ long spinal needle inserted through Tuohy needle into cerebrospinal fluid (needle‐through‐needle CSE),

‐ Subarachnoid injection of 25 g fentanyl and 2.5 mg bupivacaine

‐ Labours were managed according to the department's standard practice (cervical dilatation was assessed every 3 hours and if dilatation had not increased by 2 cm, amniotomy was performed. If the membranes were intact, this was followed 2 hours later (if progress of labour was still inadequate) by augmentation of labour with oxytocin. If the membranes were ruptured and inadequate progress of labour was noted, then oxytocin was started without waiting for another 2 hours.

‐ The mothers were allowed up to 2 hours in the second stage of labour. If at the end of the second hour, birth was not imminent, instrumental birth was performed.

Outcomes

Maternal Outcomes:

1. Mode of birth.

2. Analgesia amount.

3. Augmentation of labour using oxytocin.

Neonatal Outcomes:

1. Apgar scores.

Notes

Duration was recorded as the time between epidural insertion (highly variable) and birth (end of second stage). It was therefore not used as a comparable duration of first stage of labour.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Not stated.

Allocation concealment (selection bias)

Low risk

Described as 'sealed opaque numbered envelopes'.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

Unclear risk

Described as 'Obstetrician was not aware which group the mother was in'.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No stated losses to follow‐up.

Selective reporting (reporting bias)

Unclear risk

Unclear.

Methods

Randomised trial of women receiving a CSE.

Participants

40 women, London, U.K.

• 20 study participants: nulliparous

• 20 control participants: nulliparous

Inclusion Criteria:

Parity: nulliparous,

Pluralty: not stated,

Gestation: not stated,

Onset of labour: not stated,

Other: requesting regional analgesia.

Interventions

Study group:

• 20 women were allocated to be out of bed (sitting in rocking chair, stand by bed, walk about).

Control group:

• 20 women were allocated to staying in bed.

All women:

‐ spinal injection of bupivacaine 2.5 mg and fentanyl 25 g using a 27 gauge, 1119 mm Becton‐Dickinson Whitacre spinal needle through a 16‐gauge Braun Tuohy needle, followed by epidural top ups of 10 mg bupivacaine in 10 mL with 2 g/mL of fentanyl.

Outcomes

Maternal Outcomes:

Nil

Neonatal Outcomes:

1. Apgar scores.

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Described as 'randomly allocated'.

Allocation concealment (selection bias)

Unclear risk

Not stated.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No stated losses to follow‐up.

Selective reporting (reporting bias)

High risk

No maternal outcomes reported.

Methods

Randomised trial of patients who expressed an interest in ambulation when they were admitted in labour. During the antenatal period they had been informed that a certain number of patients could walk around while being continuously monitored in labour.

Participants

68 women, Birmingham, U.K.

• 34 study participants:17 primigravidae, 17 multigravida

• 34 control participants:17 primigravidae, 17 multigravida

Inclusion Criteria:

Parity: mixed,

Pluralty: not stated,

Gestation: not stated,

Onset of labour: spontaneous,

Other: expressing an interest in ambulation.

Interventions

Study group:

• 34 women were allowed to walk around while being continuously monitored by telemetry.

When intravenous treatment was necessary (e.g. because of ketonuria or delay in labour) the women returned to bed.

Control group:

• 34 women were nursed in the lateral position (recumbent) with conventional bedside monitoring of fetal heart and intrauterine pressure.

All women:

‐ were nursed in bed during the second and third stages of labour.
‐ Dilatation of the cervix and station of the presenting part were assessed at the start of monitoring and every two to three hours during labour.
‐ Analgesia was administered when the midwife thought the woman was becoming distressed with pain.
‐ Augmentation in labour with oxytocin or prostaglandin was given when indicated by delay in labour.

There was 33 cephalic and 1 breech presentation in each group.

Outcomes

Maternal Outcomes:

1. Duration of first stage of labour.

2. Mode of birth.

3. Maternal pain.

4. Analgesia type.

5. Augmentation of labour using oxytocin.

Neonatal Outcomes:

1. Fetal distress requiring immediate birth.

Notes

Assisted breech births (1 upright, 1 recumbent) not included as spontaneous vaginal, operative vaginal or caesarean births.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Described as 'randomised prospective'.

Allocation concealment (selection bias)

Unclear risk

Not stated.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No stated losses to follow‐up.

Selective reporting (reporting bias)

Unclear risk

Unclear.

Methods

Randomised trial of women requesting epidural anaesthesia.

Participants

61 women, Grenoble, France.

• 30 study participants: 18 primigravidae, 12 multigravida

• 31 control participants: 18 primigravidae, 13 multigravida

Inclusion Criteria:

Parity: mixed,

Pluralty: singleton,

Gestation: 37 to 42 weeks,

Onset of labour: spontaneous or admitted for elective induction,

Other: fixed cephalic uncomplicated presentation; 3 to 5 cm cervical dilatation at the time of epidural insertion; uncomplicated pregnancy; a normal fetal heart rate pattern.

Exclusion criteria ‐ unfixed cephalic presentation, cervical dilatation more than 5 cm, a contraindication to epidural analgesia, or a systolic arterial blood pressure < 100 mmHg before epidural insertion, twin pregnancy, history of caesarean birth, and any known complications of pregnancy including breech presentation.

Interventions

Study group:

• 30 women were randomised to ambulation

Women were asked to walk at least 15 mins of each hour or for 25% of the duration of the first stage of labour.
Ambulation was permitted 15 to 20 mins after the initial injection, provided there was no postural hypotension, no motor block in lower limbs, no proprioception impairment and no fetal heart rate decelerations.
The women were asked to return to bed when they requested an epidural top‐up or if they experienced weakness or sensory changes. Walking ended when examination by a midwife revealed full cervical dilatation.

Control group:

• 31 women were allocated to be recumbent

Confined to bed in dorsal or lateral recumbent position.
Monitoring of labour was as for the ambulatory group, but without telemetry. Epidural analgesia of intermittent administrations of 0.08% bupivacaine‐epinephrine plus 1 g/mL of sufentanil.

Outcomes

Maternal Outcomes:

1. Mode of birth.

2. Analgesia amount.

3. Augmentation of labour using oxytocin.

4. Hypotension requiring intervention.

Neonatal Outcomes:

1. Apgar scores.

Notes

Duration was recorded as the time between epidural insertion (highly variable) and complete cervical dilatation. It was therefore not used as a comparable duration of first stage of labour.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Not stated.

Allocation concealment (selection bias)

Low risk

Described as 'sealed numbered envelopes'.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No stated losses to follow‐up.

Selective reporting (reporting bias)

Unclear risk

Unclear.

Methods

Randomised trial.

Participants

188 women, Taiwan, Republic of China.

• 94 study participants:33 primigravidae, 15 multigravida, 46 mixed parity.

• 94 control participants: 22 primigravidae, 17 multigravida, 55 mixed parity.

Inclusion Criteria:

Parity: mixed,

Pluralty: singleton,

Gestation: unclear,

Onset of labour: spontaneous or admitted for elective induction,

Other: older than 18 years of age; no major obstetric or medical pregnancy complications; normal extremities and ability to undertake activities; a partner who was to be present during labour; and the ability to speak; read and write Chinese.

Interventions

Study group:

• 48 women were randomised to the birth ball exercise group

The birth ball exercise programme consisted of a 26 page booklet and a 19‐minute videotape, with periodic follow‐ups during prenatal checks. All women were asked to practise the exercises and positions at home for at least 20 mins three times a week for a period of 6‐8 weeks. During labour, women in the study group were given a birth ball for use during labour and encouraged every hour to choose the most comfortable positions, movements and exercises.

There were 46 post‐randomisation exclusions from the study group: Reasons for exclusion included: did not follow protocol (n = 3); epidural anaesthesia (n = 16); emergency caesarean (n = 18); preterm labour (n = 6); delivery at other hospital (n = 3).

Control group:

• 39 women were randomised to the control group

There were 55 post‐randomisation exclusions from the control group: Reasons for exclusion included: epidural anaesthesia (n = 25); emergency caesarean (n = 22); preterm labour (n = 6); delivery at other hospital (n = 2).

Outcomes

Maternal Outcomes:

1. Duration of first stage of labour.

2. Mode of birth.

3. Analgesia type.

4. Maternal pain.

5. Duration of second stage of labour.

Neonatal Outcomes:

1. Apgar scores.

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

A computer‐generated block randomisation list (with block‐sizes of four and eight varied randomly) was independently prepared by a statistician.

Allocation concealment (selection bias)

Low risk

Sequentially numbered, sealed opaque envelopes contained allocation to the appropriate group.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

High risk

There was an attrition rate of 53.7%. The reasons 101 women were removed from the study included: emergency caesarean; epidural anaesthesia; preterm labour; delivery at other hospital; not following the protocol.

All outcome data for women excluded from the study were not included in the results.

Selective reporting (reporting bias)

High risk

Study analysis which included the participants who did not follow the study protocol was repeated as ITT analysis. The authors stated there was no significant differences in effects based on ITT, but the outcome data for those and other excluded participants were not reported.

Methods

Quasi‐randomised trial.

Participants

60 women, Helsinki, Finland.

• 31 study participants:13 primigravidae, 18 multigravida

• 29 control participants: 12 primigravidae, 17 multigravida

Inclusion Criteria:

Parity: mixed,

Pluralty: not stated,

Gestation: between 38 and 42 weeks,

Onset of labour: not stated,

Other: healthy, uneventful pregnancy.

Interventions

Study group:

• 31 women having cardiotocography by telemetry (upright).

Telemetry women were encouraged to sit or walk during the opening phase of labour.

Control group:

• 29 women were randomised to have conventional cardiotocography (bed care).

All women:

‐ nitrous oxide‐oxygen, pethidine (usual dose 75 mg given once or twice) or epidural block were used for analgesia when needed.

Outcomes

Maternal Outcomes:

1. Duration of first stage of labour.

2. Mode of birth.

3. Maternal pain.

4. Analgesia type.

5. Augmentation of labour using oxytocin.

6. Artificial rupture of membranes.

Neonatal Outcomes:

1. Apgar scores.

2. Perinatal mortality.

Notes

Pooled data used from nulliparous and multiparous durations of first stage labour.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Described as matched pairs 'allocated at random' to one of two groups. Patients were matched for age, parity and duration of pregnancy.

Allocation concealment (selection bias)

Unclear risk

Not stated.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No stated losses to follow‐up.

Selective reporting (reporting bias)

Unclear risk

Unclear.

Methods

Randomised trial.

Participants

221 women, Evry, France

• 144 study participants: 97 primigravidae, 47 multigravida

• 77 control participants: 47 primigravidae, 30 multigravida

Inclusion Criteria:

Parity: mixed,

Pluralty: singleton,

Gestation: between 36 and 42 weeks,

Onset of labour: spontaneous or scheduled for induced labour,

Other: uncomplicated pregnancies.

Exclusion criteria ‐ women with pre‐eclampsia or previous caesarean.

Interventions

Study group:

• 144 women were assigned to the ambulatory group

Women could walk, sit in a chair or reclined in a semi‐supine position (n = 141), as long as they demonstrated: acceptable analgesia; acceptable systolic blood pressure and ability to stand on one leg.

3 women in this group were excluded because they had a fast birth.

Control group:

• 77 women were allocated to the non‐ambulatory group

Women were not allowed to sit, walk or go to the toilet, they had to remain in the supine position or to lie in a semi‐supine or lateral position (n = 74).

2 women in this group were excluded because they had a fast birth, and another 1 woman was excluded because of inadvertent dural puncture.

All women:

‐ Study conducted in daytime only (as women in labour at night are less inclined to walk).

‐ Received intermittent epidural injection of 0.1% ropivacaine with 0.6 µg/mL sufentanil.

‐ Repeat injections were given when the women requested additional pain relief.

Outcomes

Maternal Outcomes:

1. Mode of birth.

2. Maternal pain.

3. Analgesia amount.

4. Augmentation using oxytocin.

Neonatal Outcomes:

Nil

Notes

Duration was recorded as the time between epidural insertion (highly variable) and birth (end of second stage). It was therefore not used as a comparable duration of first stage of labour.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

'Randomly divided' in a 2:1 ratio.

Allocation concealment (selection bias)

Unclear risk

Not stated.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

High risk

6 women were excluded after randomisation.

Selective reporting (reporting bias)

Unclear risk

Unclear.

Methods

Randomised trial.

Participants

196 women, Adelaide, Australia.

• 96 study participants: 49 primigravidae, 47 multigravida

• 100 control participants: 43 primigravidae, 57 multigravida

Inclusion Criteria:

Parity: mixed,

Pluralty: singleton,

Gestation: between 37 and 42 weeks,

Onset of labour: spontaneous,

Other: cephalic presentation; in established labour (presence of regular contractions less than 10 mins apart and cervical dilatation of 3 cm or more); able to ambulate in labour.

Exclusion criteria: women undergoing intravenous therapy, with hypertension (> 90 mmHg diastolic blood pressure), epidural or narcotic analgesia at or before entry to trial, evidence of possible fetal distress, previous prostaglandin treatment, induced labour and a physical inability to ambulate.

Interventions

Study group:

• 96 women were randomised to ambulate with fetal heart radiotelemetry

Women were encouraged to ambulate but were also given the option of sitting or lying down when they wished.

Only 37 women actually chose to ambulate for half an hour or more. The mean time they spent upright was 1.8 hrs, and the mean time they spent recumbent was 4.5 hrs.

Control group:

• 100 women were randomised to recumbence with conventional fixed electronic fetal heart rate monitoring.

Most women chose a semi‐recumbent posture with the head end of the bed at 45 degrees but they could also be on their side with lower elevation of the head.

All women:

After entry to the trial, all women had an artificial rupture of the membranes if they had not already spontaneously ruptured.

Outcomes

Maternal Outcomes:

1. Mode of birth.

2. Analgesia type.

3. Augmentation of labour using oxytocin.

Neonatal Outcomes:

1. Apgar scores.

2. Admission to NICU.

3. Perinatal mortality.

Notes

Duration was recorded as the time between entry (highly variable) and birth (end of second stage). It was therefore not used as a comparable duration of first stage of labour.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Described as 'Balanced variable blocks with stratification by parity'.

Allocation concealment (selection bias)

Low risk

Opaque, sealed envelopes.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No stated losses to follow‐up.

Selective reporting (reporting bias)

Unclear risk

Unclear.

Methods

Randomised controlled trial approach with post test control group design.

Participants

60 women, Magalore, India.

• 40 study participants: nulliparous

• 20 control participants: nulliparous

Inclusion Criteria:

Parity: nulliparous,

Pluralty: not stated,

Gestation: not stated,

Onset of labour: not stated,

Other: Nil stated.

Interventions

Study group:

• 20 women were asked to ambulate

• 20 women were given a birthing ball and asked to use it

Control group:

• 20 women were confined to bed in dorsal or lateral recumbence.

Outcomes

Maternal Outcomes:

1. Duration of first stage of labour.

2. Mode of birth

3. Duration of second stage of labour.

Neonatal Outcomes:

Nil.

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

High risk

Purposive sampling technique was used for the selection of samples.

Allocation concealment (selection bias)

Unclear risk

Random allocation of 20 samples to each of the three groups was achieved using a lottery method.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

High risk

There was missing data for the duration for 1st and 2nd stage labour: ambulation (n = 2), control (n = 4), but no missing data from the birthing ball group.

There was no explanation to explain the missing data.

In one table, 2 out of 24 women in the ambulation group are reported as having had a caesarean birth, but this is contradictory to the other reported data of zero caesarean births from 20 participants in the ambulation group.

Selective reporting (reporting bias)

High risk

All methods of birth outcome data were reported, but not all durations of birth data were reported.

Methods

Randomised trial of women undergoing induction of labour.

Participants

40 women, Glasgow, U.K.

• 20 study participants: 10 primigravidae, 10 multigravida

• 20 control participants: 10 primigravidae, 10 multigravida

Inclusion Criteria:

Parity: mixed,

Pluralty: singleton,

Gestation: 38 weeks or more,

Onset of labour: induced,

Other: cervical score 6 or greater.

Exclusion criteria ‐ multiple pregnancies or breech presentations.

Interventions

Study group:

• 20 women were allocated to an upright group.

Women were encouraged to "be up and about". If woman wished to go to bed, she was nursed in a sitting position with the aid of pillows.

Control group:

• 20 women were allocated to a recumbent group.

Women were nursed in the lateral position.

All women:

Labour was induced by forewater amniotomy and 0.5 mg PGE2 immediately after amniotomy and hourly thereafter until labour was considered to be established.
If labour was not established an hour after the 6th PGE2 tablet (i.e. 6 hours after amniotomy), intravenous oxytocin was given.

Outcomes

Maternal Outcomes:

1. Mode of birth.

2. Analgesia type.

3. Augmentation of labour using oxytocin.

4. Artificial Rupture of Membranes.

5. Estimated Blood loss > 500 mL.

Neonatal Outcomes:

1. Fetal distress (requiring immediate birth).

2. Use of neonatal mechanical ventilation

3. Apgar scores.

Notes

Duration was recorded as the time between induction (highly variable) and birth (end of second stage). It was therefore not used as a comparable duration of first stage of labour.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Described as 'randomised prospective study'.

Allocation concealment (selection bias)

Low risk

Described as 'randomly allocated according to the contents of a plain envelope'.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No stated losses to follow‐up.

Selective reporting (reporting bias)

Unclear risk

Unclear.

Methods

Randomised trial.

Participants

107 women, Campinas, Brazil

• 54 study participants: nulliparous

• 53 control participants: nulliparous

Inclusion Criteria:

Parity: nulliparous,

Pluralty: singleton,

Gestation: term,

Onset of labour: spontaneous,

Other: cephalic presentation; cervical dilation between 3 cm and 5 cm; in labour; low risk; aged 16 to 40 years.

Exclusion criteria ‐ contraindications to upright position or booked for elective caesarean birth.

Interventions

Study group:

• 54 women were encouraged to adopt upright positions.

Women received written information/education involving the use of models on the benefits of maintaining an upright position and encouraged to stand, walk, sit, crouch or kneel. If women remained supine for more than 30 mins they were encouraged to return to an upright position.

Women remained upright for 57% of the time.

Control group:

• 53 women were allocated to routine care group

Women remained upright for 28% of the time.

Women were not encouraged to adopt upright positions but were allowed to move around and adopt any position they chose.

Outcomes

Maternal Outcomes:

1. Duration of first stage of labour.

2. Mode of birth.

3. Maternal satisfaction.

4. Maternal pain.

5. Duration of second stage of labour.

6. Augmentation of labour using oxytocin.

7. Perineal trauma.

Neonatal Outcomes:

1. Apgar scores.

Notes

1. Duration of first stage labour only reported as median and P value. Symmetrical distribution assumed. Median value used as a mean to calculate standard deviation and utilise data.

2. No data for numbers of operative vaginal birth or caesarean births.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Computer‐generated.

Allocation concealment (selection bias)

Low risk

Sealed, opaque envelopes opened sequentially.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Few women lost to follow‐up but no data for numbers of operative vaginal birth or caesarean births.

Selective reporting (reporting bias)

High risk

Reported data for the number of women having spontaneous vaginal birth, but not for operative births or caesarean births.

Methods

Randomised trial.

Participants

100 women, Terre Haute, U.S.A.

• 50 study participants: nulliparous

• 50 control participants: nulliparous

Inclusion Criteria:

Parity: nulliparous,

Pluralty: not stated,

Gestation: term,

Onset of labour: spontaneous,

Other: cephalic presentation; latent phase of labour or the active phase with the cervix between 1 cm and 3 cm; admitted to the labour room; no evidence of cephalopelvic disproportion; no history of surgery or trauma to the cervix; normal prenatal course.

Interventions

Study group:

• 50 women were randomised the sitting group.

All women were allowed to sit up after the amniotomy had been performed and the presenting part was engaged. The women were allowed to lie down from time to time, if they desired.

Control group:

• 50 women were allocated to the supine group.

Women were placed in the supine position and allowed to turn on their sides.
Direct fetal and maternal monitoring was performed randomly on several women in both groups, using a choriometric unit.

Outcomes

Maternal Outcomes:

1. Duration of first stage of labour.

Neonatal Outcomes:

Nil

Notes

1. SD's from the mean time in active labour (time to birth) used for the active 'phase' of labour duration times.

Apgar scores only provided as a mean value.

It is not clear if all women in both groups had routine amniotomy.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Described as 'divided randomly into two groups'.

Allocation concealment (selection bias)

Unclear risk

Not stated.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No stated losses to follow‐up.

Selective reporting (reporting bias)

High risk

Claimed evidence of an outcome with little or no data to support it.

Methods

Randomised trial.

Participants

761 women, California, U.S.A.

• 253 study participants: nulliparous

• 252 control participants:nulliparous

• 256 participants not used for this review because they received a different epidural intervention: nulliparous.

Inclusion Criteria:

Parity: nulliparous,

Pluralty: not stated,

Gestation: 36 weeks or more,

Onset of labour: spontaneous or induced for spontaneous rupture of membranes at 36 weeks or more,

Other: fetus in the vertex position; requesting epidural analgesia.

Interventions

Study group:

• 253 women were encouraged to ambulate (n = 253).

Ambulation was defined as a minimum of five mins of walking per hour.

Control group:

• 252 women were discouraged to ambulate.

All women:

‐ had CSE.
‐ received a minimum of 1000 mL of lactated Ringer's solution intravenously during the 30 mins preceding the placement of the epidural needle. CSE ‐ intrathecal narcotic with a continuous low‐dose epidural infusion. After the location of the epidural space with an 18‐gauge Tuohy needle, a 11.9 cm 27‐gauge Whitacre spinal needle was passed through the epidural needle into the subarachnoid space. Then 10 g of sufentanil in 2 mL of normal saline was infused and the spinal needle removed. An epidural catheter was advanced 3 cm into the epidural space and a continuous infusion of 0.0625 % bupivacaine with 2 g of fentanyl per millilitre was given at a rate of 12 mL per hour.
‐ Subsequent bolus doses of epidural solution were given as requested (12 mL of 0.0625% bupivacaine).

Outcomes

Maternal Outcomes:

1. Mode of birth.

2. Maternal pain.

3. Hypotension requiring intervention.

Neonatal Outcomes:

1. Apgar scores.

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Described as 'randomly assigned'.

Allocation concealment (selection bias)

Unclear risk

Not stated.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No stated losses to follow‐up.

Selective reporting (reporting bias)

Unclear risk

Unclear.

Methods

Randomised trial. Randomised in blocks.

Participants

204 women, Southern Thailand.

• 40 study participants: primiparous

• 43 control participants: primiparous

• 121 participants not used for this review: primiparous

Inclusion Criteria:

Parity: nulliparous,

Pluralty: singleton,

Gestation: 38 ‐ 42 weeks,

Onset of labour: spontaneous,

Other: cephalic presentation; in latent phase for > 10 hours; married; aged 18 ‐ 35 years; fetal weight 2500 ‐ 4000 g.

Exclusion criteria: had analgesia before recruitment; induced labour; membrane rupture > 20 hours previously; psychiatric problem; infection; asthma or objection to intervention.

5 separate intervention groups (described below). In this review we have included data from two groups:

Interventions

Study group:

• 40 women were allocated to use the CAT position alternating half hourly with head high position (CAT position = facing towards bed head at 45 degrees with knees bent, taking weight on knees and elbows; head high position = lying at a 45‐degree angle) (n = 40).

Control group:

• 43 women were assigned to remain supine in bed.

Outcomes

Maternal Outcomes:

1. Duration of first stage of labour.

Neonatal Outcomes:

Nil.

Notes

Complicated study design with five study groups:
1. CAT position alternating with head‐high position with music (n = 40).
2. CAT position alternating with head‐high position (n = 40).
3. CAT position alternating with supine position (n = 40).
4. Head‐high position (lying in bed on back at 45 degrees) (n = 41).
5. Supine in bed (n = 43).

In this review we have used data for groups 2 and 5 in the analyses.

(It was not clear what 'CAT' signified)

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

No information.

Allocation concealment (selection bias)

Unclear risk

Described as 'random block design'.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Three women were lost to follow‐up as they had caesarean births during the first stage of labour. It was not clear whether this was before randomisation. No other loss to follow‐up was apparent.

Selective reporting (reporting bias)

Unclear risk

Unclear.

Methods

Randomised trial.

Participants

62 women, Tehran, Iran.

• 31 study participants: nulliparous

• 31 control participants: nulliparous

Inclusion Criteria:

Parity: nulliparous,

Pluralty: singleton,

Gestation: 38 ‐ 40 weeks,

Onset of labour: spontaneous,

Other: cephalic presentation; cervical dilatation between 4 to 8 cm; anticipation of a normal birth; no history of infertility; aged 18 to 25 years.

Interventions

Study group:

• 29 women were allocated to use a birth ball

There were two post randomisation exclusions from the study group. Reasons included: dissatisfied with sitting on the ball during birth ball movements (n = 1); caesarean birth because of lack of descent of the fetal head (n = 1).

Control group:

• 31 women were allocated to usual care.

Routine care consists of the parturient lying on the bed without ambulating or any intervention.

Outcomes

Maternal Outcomes:

1. Duration of first stage labour.

2. Mode of birth

3. Maternal pain

Neonatal Outcomes:

Nil.

Notes

1. Duration of first stage labour reported as duration of active phase.

2. No mode of birth outcomes for vaginal birth or operative vaginal birth were given.

If there was a need for analgesic medication, or if obstetric complications occurred, the participant was immediately referred to an obstetrician and other professionals as needed, then excluded from the study.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

High risk

60 volunteer women (convenience sample) were randomly allocated using a table of random numbers.

Allocation concealment (selection bias)

High risk

If the number was even, women were assigned to the birth ball group, if the number was odd, women were assigned to control group.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Low risk

The individual responsible for data analysis was masked to the study purposes to minimise any bias that might arise from knowledge about the participants.

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

There were two post randomisation exclusions reported: dissatisfied with sitting on the ball during birth ball movements (n = 1); caesarean birth because of lack of descent of the fetal head (n = 1).

The total number of participants included for duration of labour and maternal pain data is not clearly stated. It is unclear if the number includes totals before or after exclusions. It is also not clear if the group numbers were even before or after the exclusions.

Selective reporting (reporting bias)

Unclear risk

Unclear.

Methods

Randomised trial.

Participants

160 women, Pennsylvania, U.S.A.

• 75 study participants: nulliparous

• 76 control participants nulliparous

Inclusion Criteria:

Parity: nulliparous,

Pluralty: singleton,

Gestation: 36 ‐ 42 weeks,

Onset of labour: spontaneous or induction of labour,

Other: vertex position; 3‐5 cm cervical dilatation at the time of epidural insertion; uncomplicated pregnancies.

Exclusion criteria ‐ pre‐eclampsia, diabetes mellitus, preterm gestation (< 36 weeks) and post‐term gestation (> 42 weeks).

Interventions

Study group:

• 75 women were allocated to AEA with ambulation, sitting in a chair or both.

After 1 hour, women with a modified Bromage score of 5 who could stand on one foot (right and left) without assistance (all women in this group were able to do this) and without hypotension (systolic blood pressure < 100 mmHg or a decrease of 20 mmHg), were encouraged to ambulate with a support person (spouse or friend). If the woman could not comply with ambulation, she was encouraged to sit in a chair.
Ambulation was defined as a minimum of 5 min of walking per hour.
Women were not allowed to ambulate if there were persistent fetal decelerations and were not allowed to be out of bed in the second stage of labour when women were actively pushing.

Control group:

• 76 women were assigned to AEA without ambulation or sitting in a chair.

Women were confined to bed, encouraged to stay recumbent in a lateral position, and were not allowed to raise the head of the bed more than 45 degrees from horizontal.

All women:

‐ AEA blocks initiated with 15 to 25 mL ropivacaine (0.07%) plus 100 g/mL fentanyl, no test dose, to achieve a T10 dermatome sensory level. After achieving adequate pain relief, a continuous infusion of 0.07% ropivacaine plus 2 g/mL fentanyl at 15 to 20 mL/hour was administered.

Outcomes

Maternal Outcomes:

1. Mode of birth.

2. Analgesia amount.

3. Duration of second stage of labour.

4. Augmentation of labour using oxytocin.

Neonatal Outcomes:

1. Apgar scores.

Notes

Duration was recorded as the time between epidural insertion (highly variable) and complete cervical dilatation. It was therefore not used as a comparable duration of first stage of labour.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Described as 'random number computer‐generated program'.

Allocation concealment (selection bias)

Unclear risk

Not stated.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

High risk

9 women were excluded.

Selective reporting (reporting bias)

Unclear risk

Unclear.

Methods

Quasi‐randomised trial.

Participants

300 women, London, U.K.

• 48 study participants: 25 primigravidae, 23 multigravida

• 55 control participants: 30 primigravidae, 25 multigravida

• 197 participants were excluded: short first stage (n = 84); at risk pregnancy (n = 29); induction (n = 24); refused ambulation (n = 30), elective caesarean birth (n = 13); stillbirths (n = 5); meconium‐stained liquor (n = 5); breech (n = 3); twin pregnancy (n = 2); birth before arrival (n = 2).

Inclusion Criteria:

Parity: mixed,

Pluralty: singleton,

Gestation: 36‐42 weeks,

Onset of labour: spontaneous,

Other: nil stated.

Interventions

Study group:

• 48 women were assigned to the ambulant group.

Women were informed about the possible benefits of ambulation and were encouraged to walk about during the first stage of labour
Women who refused ambulation or who requested to return to bed were allowed to do so.
Any woman who developed abnormalities of the fetal heart rate or fresh meconium staining of the amniotic fluid was returned to bed
Women who requested or who were advised to have an epidural also returned to bed but those requiring oxytocin augmentation of labour carried their intravenous infusions with them.

Control group:

• 55 women were allocated to the non ambulant group.

Outcomes

Maternal Outcomes:

1. Duration of first stage of labour.

2. Mode of birth.

3. Analgesia type.

4. Duration of second stage of labour.

Neonatal Outcomes:

1. Apgar scores.

Notes

Pooled data used from nulliparous and multiparous durations of first stage labour.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

High risk

Described as 'divided into two groups according to their hospital number'.

Allocation concealment (selection bias)

High risk

See above.

Blinding (performance bias and detection bias)
Women

High risk

Not feasible.

Blinding (performance bias and detection bias)
Clinical staff

High risk

Not feasible.

Blinding (performance bias and detection bias)
Outcome assessor

Unclear risk

Not stated.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No stated losses to follow‐up.

Selective reporting (reporting bias)

Unclear risk

Unclear.