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

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

doi:10.1002/14651858.CD008070.pub4

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Figure 1

Study flow diagram.

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Figure 2

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

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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Analysis 1.1

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

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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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Analysis 1.3

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

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Analysis 1.4

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

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Analysis 1.5

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

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Analysis 1.6

Comparison 1 Upright position versus recumbent position, Outcome 6 Blood loss (greater than 500 mL) (trial authors defined it as PPH requiring blood transfusion).

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Analysis 1.7

Comparison 1 Upright position versus recumbent position, Outcome 7 Prolonged second stage, defined as pushing for more than 60 minutes (trial authors report 'duration of pushing phase' in minutes.

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Analysis 1.8

Comparison 1 Upright position versus recumbent position, Outcome 8 Maternal experience and satisfaction of labour.

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Analysis 1.9

Comparison 1 Upright position versus recumbent position, Outcome 9 Abnormal fetal heart rate patterns, requiring intervention.

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Analysis 1.10

Comparison 1 Upright position versus recumbent position, Outcome 10 Apgar score less than seven at five minutes.

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Analysis 1.11

Comparison 1 Upright position versus recumbent position, Outcome 11 Apgar score less than four at five minutes.

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Analysis 1.12

Comparison 1 Upright position versus recumbent position, Outcome 12 Low cord pH.

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Analysis 1.13

Comparison 1 Upright position versus recumbent position, Outcome 13 Admission to neonatal intensive care unit.

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Analysis 1.14

Comparison 1 Upright position versus recumbent position, Outcome 14 Need for ventilation (trial authors report 'intubation').

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Analysis 1.15

Comparison 1 Upright position versus recumbent position, Outcome 15 Perinatal death.

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Analysis 2.1

Comparison 2 Upright position versus recumbent position (sensitivity analyses ‐ high‐quality studies only), Outcome 1 Operative birth (caesarean or instrumental vaginal).

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Analysis 2.2

Comparison 2 Upright position versus recumbent position (sensitivity analyses ‐ high‐quality studies only), Outcome 2 Caesarean section.

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Analysis 2.3

Comparison 2 Upright position versus recumbent position (sensitivity analyses ‐ high‐quality studies only), Outcome 3 Instrumental vaginal birth.

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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 in the second stage of labour with epidural anaesthesia Setting: hospital setting in the UK, France and Spain Intervention: upright position Comparison: recumbent position
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
	Risk with recumbent position	Risk with upright position
Maternal outcomes
Operative birth (caesarean or instrumental vaginal)	Study population		RR 0.86 (0.70 to 1.07)	4316 (8 RCTs)	⊕⊕⊝⊝ LOW ^a,b	‐
	554 per 1000	476 per 1000 (382 to 592)
Duration of second stage labour (minutes) (from time of randomisation to birth)	The mean duration of second stage labour across control groups ranged from 52.06 minutes to 124.3 minutes	MD 6.00 minutes higher (37.46 lower to 49.46 higher)	‐	456 (3 RCTs)	⊕⊝⊝⊝ VERY LOW^a,c,d	‐
Caesarean section	Study population		RR 0.94 (0.61 to 1.46)	4316 (8 RCTs)	⊕⊝⊝⊝ VERY LOW^a,e,f	‐
	86 per 1000	81 per 1000 (52 to 125)
Instrumental vaginal birth	Study population		RR 0.90 (0.72 to 1.12)	4316 (8 RCTs)	⊕⊝⊝⊝ VERY LOW^a,f,g	‐
	468 per 1000	421 per 1000 (337 to 524)
Trauma to birth canal requiring suturing	Study population		RR 1.00 (0.89 to 1.13)	3266 (3 RCTs)	⊕⊕⊝⊝ LOW^h,i	‐
	840 per 1000	832 per 1000 (714 to 975)
Blood loss (greater than 500 mL) (trial authors defined it as PPH requiring blood transfusion)	Study population		RR 1.20 (0.83 to 1.72)	3093 (1 RCT)	⊕⊕⊕⊝ MODERATE^f,,j	‐
	34 per 1000	41 per 1000 (28 to 58)
Infant outcomes
Abnormal fetal heart rate patterns, requiring intervention	Study population		RR 1.69 (0.32 to 8.84)	107 (1 RCT)	⊕⊝⊝⊝ VERY LOW^k,l	‐
	41 per 1000	69 per 1000 (13 to 361)
Low cord pH	Study population		RR 0.43 (0.20 to 0.90)	3159 (2 RCTs)	⊕⊕⊕⊝ MODERATE^m	‐
	16 per 1000	7 per 1000 (3 to 14)
Admission to neonatal intensive care unit	Study population		RR 0.54 (0.02 to 12.73)	66 (1 RCT)	⊕⊝⊝⊝ VERY LOW^l,n	‐
	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 certainty: we are very confident that the true effect lies close to that of the estimate of the effect Moderate certainty: 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 certainty: our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low certainty: we have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
^aLimitations in study (no blinding possible in any of the studies, with some studies at high risk for incomplete data, selective reporting and other bias) (‐1). ^bHigh heterogeneity (I² = 78%) overall and in separate subgroups, mobile epidural (I² = 43%), traditional epidurals (81%) (‐1). ^cVery high heterogeneity (I² = 96%) (‐1). ^dWide CI – from 37 minutes lower to 50 minutes higher (‐1). ^eModerate heterogeneity (I² = 47%) overall (‐1). ^fWide CI crossing the line of no effect (‐1). ^gModerate heterogeneity (I² = 69%) overall (‐1). ^hLimitations in study design (no blinding, unclear allocation concealment, incomplete outcome data, selective reporting, unclear and high risk of other bias) (‐1). ⁱModerate heterogeneity (I² = 46%) (‐1). ^jNot downgraded for lack of blinding because an objective measure. ^kLimitations in study design (no blinding, unclear allocation concealment, unclear incomplete outcome data and other bias) (‐1). ^lSingle study with small number of events and sample size and wide CI crossing the line of no effect (‐2). ^mLimitations in study design (lack of blinding (although it is probably an objective measure), unclear allocation concealment, incomplete outcome data, selective reporting, other bias) (‐1). ⁿLimitations in study design (no blinding, unclear selection bias) (‐1).

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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Summary of findings 2. Upright position compared to recumbent position (sensitivity analyses ‐ studies at low risk of bias only) for the second stage of labour for women with epidural anaesthesia

Upright position compared to recumbent position (sensitivity analyses ‐ studies at low risk of bias only) for the second stage of labour for women with epidural anaesthesia
Patient or population: women in the second stage of labour with epidural anaesthesia Setting: hospital setting in the UK Intervention: upright position Comparison: recumbent position
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
	Risk with recumbent position (sensitivity analyses ‐ studies at low risk of bias only)	Risk with upright position
Operative birth (caesarean or instrumental vaginal)	Study population		RR 1.11 (1.03 to 1.20)	3609 (3 RCTs)	⊕⊕⊕⊕ HIGH^a	‐
	573 per 1000	636 per 1000 (590 to 688)
Caesarean section	Study population		RR 1.29 (1.05 to 1.57)	3609 (3 RCTs)	⊕⊕⊕⊕ HIGH^a	‐
	86 per 1000	111 per 1000 (90 to 135)
Instrumental vaginal birth	Study population		RR 1.08 (0.91 to 1.30)	3609 (3 RCTs)	⊕⊕⊝⊝ LOW^a,b,c	‐
	487 per 1000	526 per 1000 (443 to 633)
*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 certainty: We are very confident that the true effect lies close to that of the estimate of the effect Moderate certainty: 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 certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
^aLimitations in study design (no blinding possible in any of the studies, unclear allocation concealment) – but most of the pooled effect comes from one study with low risk of bias for all domains apart from blinding – impossible to blind and so not downgraded for lack blinding as this is an objective measure. ^bModerate heterogeneity (I² = 49%). ^cWide CI crossing line of no effect.

Summary of findings 2. Upright position compared to recumbent position (sensitivity analyses ‐ studies at low risk of bias only) 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	8	4316	Risk Ratio (M‐H, Random, 95% CI)	0.86 [0.70, 1.07]

1.1 'Mobile' epidurals	4	3783	Risk Ratio (M‐H, Random, 95% CI)	1.04 [0.90, 1.20]
1.2 Traditional epidurals or type not specified	4	533	Risk Ratio (M‐H, Random, 95% CI)	0.77 [0.48, 1.25]
2 Duration of second stage labour (minutes) (from time of randomisation to birth) Show forest plot	3	456	Mean Difference (IV, Random, 95% CI)	6.00 [‐37.46, 49.46]

2.1 'Mobile' epidurals	0	0	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 Traditional epidurals or type not specified	3	456	Mean Difference (IV, Random, 95% CI)	6.00 [‐37.46, 49.46]
3 Caesarean section Show forest plot	8	4316	Risk Ratio (M‐H, Random, 95% CI)	0.94 [0.61, 1.46]

3.1 'Mobile' epidurals	4	3783	Risk Ratio (M‐H, Random, 95% CI)	1.14 [0.78, 1.67]
3.2 Tradtional epidurals or type not specified	4	533	Risk Ratio (M‐H, Random, 95% CI)	0.41 [0.15, 1.16]
4 Instrumental vaginal birth Show forest plot	8	4316	Risk Ratio (M‐H, Random, 95% CI)	0.90 [0.72, 1.12]

4.1 'Mobile' epidurals	4	3783	Risk Ratio (M‐H, Random, 95% CI)	1.06 [1.00, 1.13]
4.2 Traditional epidurals or type not specified	4	533	Risk Ratio (M‐H, Random, 95% CI)	0.84 [0.50, 1.41]
5 Trauma to birth canal requiring suturing Show forest plot	3	3266	Risk Ratio (M‐H, Random, 95% CI)	1.00 [0.89, 1.13]

6 Blood loss (greater than 500 mL) (trial authors defined it as PPH requiring blood transfusion) Show forest plot	1	3093	Risk Ratio (M‐H, Random, 95% CI)	1.20 [0.83, 1.72]

7 Prolonged second stage, defined as pushing for more than 60 minutes (trial authors report 'duration of pushing phase' in minutes Show forest plot	1	199	Mean Difference (IV, Random, 95% CI)	‐16.37 [‐24.55, ‐8.19]

8 Maternal experience and satisfaction of labour Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

8.1 Satisfaction with overall childbirth experience (strongly agree & agree)	1	2373	Risk Ratio (M‐H, Random, 95% CI)	0.95 [0.92, 0.99]
8.2 Involved in making decisions (strongly agree & agree)	1	2373	Risk Ratio (M‐H, Random, 95% CI)	0.98 [0.96, 1.00]
8.3 Treated with respect by all staff (strongly agree & agree)	1	2373	Risk Ratio (M‐H, Random, 95% CI)	0.99 [0.98, 1.01]
8.4 Expectations for labour & birth were met (strongly agree & agree)	1	2373	Risk Ratio (M‐H, Random, 95% CI)	0.99 [0.93, 1.05]
8.5 Felt safe at all times (strongly agree & agree)	1	2373	Risk Ratio (M‐H, Random, 95% CI)	0.99 [0.97, 1.02]
8.6 Good communication from staff (strongly agree & agree)	1	2373	Risk Ratio (M‐H, Random, 95% CI)	1.00 [0.98, 1.02]
8.7 Felt in control (strongly agree & agree)	1	2373	Risk Ratio (M‐H, Random, 95% CI)	1.00 [0.95, 1.06]
8.8 Able to move as much as wanted (strongly agree & agree)	1	2373	Risk Ratio (M‐H, Random, 95% CI)	0.93 [0.86, 1.01]
8.9 Satisfied with position before pushing (strongly agree & agree)	1	2373	Risk Ratio (M‐H, Random, 95% CI)	1.02 [0.98, 1.05]
8.10 Satisfied with position while pushing (strongly agree & agree)	1	2373	Risk Ratio (M‐H, Random, 95% CI)	1.01 [0.98, 1.04]
8.11 Satisfied with labour pain relief (strongly agree & agree)	1	2373	Risk Ratio (M‐H, Random, 95% CI)	0.99 [0.97, 1.02]
9 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]

10 Apgar score less than seven at five minutes Show forest plot	1	199	Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]

11 Apgar score less than four at five minutes Show forest plot	1	3093	Risk Ratio (M‐H, Random, 95% CI)	0.66 [0.11, 3.94]

12 Low cord pH Show forest plot	2	3159	Risk Ratio (M‐H, Random, 95% CI)	0.43 [0.20, 0.90]

13 Admission to neonatal intensive care unit Show forest plot	1	66	Risk Ratio (M‐H, Random, 95% CI)	0.54 [0.02, 12.73]

14 Need for ventilation (trial authors report 'intubation') Show forest plot	1	3093	Risk Ratio (M‐H, Random, 95% CI)	0.74 [0.26, 2.13]

15 Perinatal death Show forest plot	1	3093	Risk Ratio (M‐H, Random, 95% CI)	2.96 [0.12, 72.69]

Comparison 1. Upright position versus recumbent position

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Comparison 2. Upright position versus recumbent position (sensitivity analyses ‐ high‐quality studies only)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Operative birth (caesarean or instrumental vaginal) Show forest plot	3	3609	Risk Ratio (M‐H, Random, 95% CI)	1.11 [1.03, 1.20]

1.1 'Mobile' epidurals	2	3502	Risk Ratio (M‐H, Random, 95% CI)	1.10 [1.04, 1.16]
1.2 Traditional epidurals or type not specified	1	107	Risk Ratio (M‐H, Random, 95% CI)	1.58 [0.99, 2.54]
2 Caesarean section Show forest plot	3	3609	Risk Ratio (M‐H, Random, 95% CI)	1.29 [1.05, 1.57]

2.1 'Mobile' epidurals	2	3502	Risk Ratio (M‐H, Random, 95% CI)	1.29 [1.06, 1.58]
2.2 Tradtional epidurals or type not specified	1	107	Risk Ratio (M‐H, Random, 95% CI)	0.84 [0.05, 13.16]
3 Instrumental vaginal birth Show forest plot	3	3609	Risk Ratio (M‐H, Random, 95% CI)	1.08 [0.91, 1.30]

3.1 'Mobile' epidurals	2	3502	Risk Ratio (M‐H, Random, 95% CI)	1.06 [0.98, 1.15]
3.2 Traditional epidurals or type not specified	1	107	Risk Ratio (M‐H, Random, 95% CI)	1.63 [1.00, 2.68]

Comparison 2. Upright position versus recumbent position (sensitivity analyses ‐ high‐quality studies only)

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