Summary of the main findings for comparison 2
3.3 Second stage of labour
3.3.3 Birth position for women with epidural analgesia RECOMMENDATION 35
3. EVIDENCE AND RECOMMENDATIONS
3.3.3 Birth position for women with epidural analgesia
WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE
suturing (3 trials, 3266 women, RR 1.01, 95% CI 0.89–1.14).
Maternal morbidity: No studies reported PPH or other morbidity outcomes, although one study (3093 women) reported the number of women with blood loss requiring transfusion; low-certainty evidence suggests there may be little or no difference between groups for this outcome (RR 1.20, 95% CI 0.83–1.72).
Birth experience: One study (3093 women) reported on the number of women expressing satisfaction with their overall childbirth experience;
moderate-certainty evidence suggests there is probably little or no difference between groups (RR 0.98, 95% CI 0.93–1.03).
Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: Low-certainty evidence from two studies (3200 infants) suggests there may be little or no difference in Apgar scores below 7 at 5 minutes (RR 0.66, 95% CI 0.11–3.94).
Moderate-certainty evidence suggests that low cord pH1 is probably reduced with an upright position (2 studies, 3159 infants, RR 0.43, 95% CI 0.20–0.90;
absolute difference: 9 fewer per 1000 [from 2 to 13 fewer]). Low-certainty evidence suggests there may be little or no difference in rates of neonatal resuscitation (1 study, 3093 infants, RR 1.00, 95% CI 0.75–1.32).
Fetal distress: The evidence on abnormal FHR patterns requiring intervention is of very low certainty.
Perinatal mortality: Low-certainty evidence from one study suggests little or no difference in perinatal death (there was a single event, 3093 infants, RR 2.96, 95% CI 0.12–72.69).
Additional considerations
A population-based study of 113 000 women conducted in Sweden of obstetric anal sphincter injury (OASI) and birth position found an increased risk of OASI with lithotomy position in nulliparous and parous women, a decreased risk of OASI with a lateral birth position in nulliparous women, and no clear difference in risk with supine, kneeling, standing or all-fours positions (156). Squatting and birth seats were associated with an increased risk of OASI in parous women but not in nulliparous women. Overall, 57% of nulliparous women and 26% of parous women underwent epidural analgesia
1 Low cord pH was defined as a pH of < 7.05 in one study (n = 3093) and a pH < 7.20 in the other study (n = 66).
in this study and findings were not reported separately according to its use.
Values
Findings from a review of qualitative studies looking at what matters to women during intrapartum care (23) indicate that most women want a normal childbirth with good outcomes for mother and baby (high confidence in the evidence). Findings also suggest that women are aware of the unpredictability of labour and childbirth and are fearful of potentially traumatic events (including medical interventions and maternal and fetal morbidities) so would value any technique that reduces their potential exposure to these kinds of outcomes (high confidence in the evidence).
In addition, findings suggest that women expect labour and childbirth to be painful but would like to be in control of the labour process with the support of kind, caring staff who are sensitive to their needs. Women would also like to give birth in a safe, supportive environment that may include the freedom to move around (high confidence in the evidence).
Additional considerations
Although the evidence on the effect of birth positions with epidural is limited, it suggests that birth position has little impact on outcomes for women with epidural. Therefore, based on the qualitative evidence above, women with epidurals may prefer the option of an upright birth position if it does not cause harm to them or their babies.
Resources
No research evidence was found on costs associated with birth positions.
Additional considerations
As the evidence on effects suggests there might be little or no difference in the duration of the second stage and other birth outcomes, the choice of birth position for women with epidural analgesia might plausibly have little or no resource implications with regard to staff time and beds.
Health care professionals accustomed to supporting women with epidural analgesia to give birth in recumbent positions could require additional/
refresher training on how to support them to give birth in an upright position.
3. EVIDENCE AND RECOMMENDATIONS
Equity
No research evidence on equity was found.
Additional considerations
Having a choice of birth positions might have a positive impact on equity if it reduces unnecessary medical interventions among more advantaged women using epidural analgesia.
Acceptability
A systematic review of qualitative studies exploring women’s experiences of intrapartum care (26) found that women wanted the freedom to adopt various positions during the second stage of labour (low confidence in the evidence). In most cases a non-supine position was perceived to be more empowering and less painful, and to facilitate an easier birth, although the supine position (on a bed) was still viewed as the more traditional approach to giving birth (low confidence in the evidence).
Findings on health care professionals’ experiences from the same review showed that staff tried to be responsive to women’s needs but tended to favour the supine position as it made monitoring, medical intervention and the birth process easier for them to manage (moderate confidence in the evidence) (26).
Additional considerations
Data from cross-sectional surveys conducted in Africa (Malawi and Nigeria) showed that more than 90% of women were aware of the supine or semi-recumbent positions for labour and birth but less than 5% were aware of alternative positions (e.g.
squatting, kneeling, and on hands and knees). Data from the Nigerian study also showed that only 18.9%
of women would have been prepared to adopt an alternative position if it had been suggested by a health care professional (157, 158).
Feasibility
A systematic review of qualitative studies exploring women’s experiences of intrapartum care (26) found that women generally wanted to move around during childbirth but the lack of space in some birth facilities prevented them from doing so (low confidence in the evidence). Findings also showed that women were sometimes unaware of non-supine positions and felt different options for birth positions should have been highlighted during antenatal care (low confidence in the findings).
Findings on health care professionals’ experiences of intrapartum care (26) showed that providers were often unaware of or inexperienced in the use of non-supine positions. Staff also raised safety concerns about women coming “off the bed” and in certain contexts (LMICs) felt that overcrowding in delivery rooms prevented women from adopting an upright position (low confidence in the evidence).
Additional considerations
Upright birth positions might be more feasible to implement in settings where “walking” epidurals are available, as these are less restrictive than traditional epidurals. The adoption of upright positions will require additional training and practise, as many practising doctors and midwives may not be familiar with the method. Facilities employing a younger generation of doctors and midwives may not have experienced personnel on staff, which may slow down implementation even when a policy of offering upright birth options is in place. Safety concerns about the baby falling on the floor during an expulsive second stage would need to be addressed by appropriate training and provision of supportive birthing facilities.
WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE
Table 3.50 Summary of judgements: Upright birth positions compared with recumbent birth positions in women with epidural analgesia
Desirable
effects –
Don’t know –
Varies ✓
Trivial –
Small –
Moderate –
Large Undesirable
effects –
Don’t know –
Varies –
Large –
Moderate –
Small ✓
Trivial Certainty of
the evidence –
No included studies
Very low– ✓
Low –
Moderate –
High
Values –
Important uncertainty or
variability
Possibly – important uncertainty or
variability
Probably no ✓ important uncertainty or
variability
No important – uncertainty or
variability Balance of
effects –
Don’t know –
Varies –
Favours the comparison
Probably – favours recumbent
Does not ✓ favour upright
or recumbent
Probably – favours upright
Favours – upright Resources
required –
Don’t know –
Varies –
Large costs –
Moderate costs
Negligible ✓ costs or savings
Moderate – savings
Large savings–
Certainty of evidence of required resources
No included ✓ studies
Very low– –
Low –
Moderate –
High
Cost-effectivenessa –
Don’t know –
Varies –
Favours the comparison
Probably – favours recumbent
Does not – favour upright
or recumbent
Probably – favours upright
Favours – upright
Equity ✓
Don’t know –
Varies –
Reduced –
Probably reduced
Probably no – impact
Probably – increased
Increased–
Acceptability –
Don’t know ✓
Varies –
No –
Probably No –
Probably Yes –
Yes
Feasibility –
Don’t know ✓
Varies –
No –
Probably No –
Probably Yes –
Yes
a The cost-effectiveness domain was not judged because the desirable effects of the intervention were trivial.
3. EVIDENCE AND RECOMMENDATIONS
Summary of evidence and considerations Effects of the intervention (EB Table 3.3.4) This evidence is derived from a Cochrane systematic review on pushing techniques (160). Eight RCTs involving 884 women compared spontaneous pushing with directed pushing. Most participants in these studies, which were conducted in Hong Kong Special Administrative Region, Iran, Turkey, the United Kingdom (1 study each) and the USA (3 studies), were nulliparous women with uncomplicated singleton vertex gestations at term.
Sample sizes ranged from 32 to 320 participants.
One trial (258 women) also included parous women and another comprised a proportion of women with epidural analgesia. The birth position of participants in the studies was not consistent across studies, with one study (72 women) managing the directed pushing group in a supine position, whereas women in the spontaneous group pushed in an upright position. Other aspects of the techniques differed slightly across studies but, in general, women in the spontaneous group were not given specific instructions on how to push and were encouraged, rather, to do what comes naturally.
Comparison: Spontaneous pushing compared with directed pushing
Maternal outcomes
Duration of labour: Evidence on duration of the second stage of labour and the duration of pushing is of very low certainty.
Mode of birth: High-certainty evidence shows that spontaneous pushing makes little or no difference to spontaneous vaginal birth (5 trials, 688 women, RR 1.01, 95% CI 0.97–1.05), and low-certainty evidence suggests that it may have little or no effect on instrumental vaginal birth (2 trials, 393 women, 3.3.4 Method of pushing
RECOMMENDATION 36
Women in the expulsive phase of the second stage of labour should be encouraged and supported to follow their own urge to push. (Recommended)
REMARKS
Qualitative evidence on what matters to women during intrapartum care shows that women want to feel in control of their birth process, with the support of kind, reassuring staff who are sensitive to their needs (23).
Health care providers should avoid imposing directed pushing on women in the second stage of labour, as there is no evidence of any benefit with this technique.
RR 0.56, 95% CI 0.06–5.10). Evidence on caesarean section is of very low certainty.
Perineal/vaginal trauma: Moderate-certainty evidence suggests there is probably little or no difference between spontaneous and directed pushing on perineal lacerations (1 trial, 320 women, RR 0.87, 95% CI 0.45–1.66). Evidence on episiotomy is of very low certainty.
Long-term morbidity: Low-certainty evidence suggests there may be little or no difference in postpartum urinary incontinence between spontaneous and directed pushing (1 trial, 128 women, RR 0.77, 95% CI 0.29–1.69). No studies reported perineal pain, dyspareunia or pelvic floor prolapse.
Birth experience: There may be little or no difference in maternal satisfaction between these techniques, measured on a visual analogue scale, however the evidence is of low certainty (1 trial, 31 women, MD 0.91 higher satisfaction score [from 1.3 lower to 3.12 higher]). Evidence on maternal fatigue after birth is of very low certainty and no studies reported on pain during the second stage.
Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: Low-certainty evidence suggests there may be little or no difference between spontaneous compared with directed pushing on 5-minute Apgar score less than 7 (1 trial, RR 0.35, 95% CI 0.01–8.43), umbilical arterial cord blood pH less than 7.2 (1 trial, 320 women, RR 0.74, 95% CI 0.24–2.29), and delivery room neonatal resuscitation (2 trials, 352 babies, RR 0.83, 95% CI 0.40–1.75).
Fetal distress: The review did not report this outcome.
WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE
Perinatal mortality: The review did not report this outcome.
Additional considerations
Evidence from other studies suggests that women are less likely (than health care providers) to recognize defined, time-bound phases of labour (54), and their ability to cope is more likely to be dependent on a variety of inter-related factors, including the level of pain experienced, the nature of the environment and their perceived level of support (55).
Values
Findings from a review of qualitative studies looking at what matters to women during intrapartum care (23) indicate that most women want a normal childbirth with good outcomes for mother and baby (high confidence in the evidence). Some women also hope for a relatively quick labour but this is often based on the perception that the longer labour lasts the more likely they are to require medical intervention (low confidence in the evidence).
Findings also suggest that women are aware of the unpredictability of labour and childbirth and are fearful of potentially traumatic events (including medical interventions and maternal and fetal morbidities) so they would value any technique that reduces their potential exposure to these kinds of outcomes (high confidence in the evidence).
Findings also suggest that women would like to
“go with the flow” by being aware of and trusting their own physiological signals (including the urge to push), supported by kind, reassuring staff who are sensitive to their needs (high confidence in the evidence).
Additional considerations
Evidence from other studies suggests that women are less likely (than health care providers) to recognize defined, time-bound phases of labour (54), and their ability to cope is more likely to be dependent on a variety of inter-related factors, including the level of pain experienced, the nature of the environment and their perceived level of support (55).
Resources
There is no review evidence on costs associated with these two pushing techniques.
Additional considerations
If a pushing technique leads to a longer duration of second stage and/or more interventions, it would
have cost implications in terms of staff time and other costs. However, this does not appear to be the case with spontaneous and directed pushing techniques, which, the review found, had little or no effect on the duration of labour and other birth outcomes. Therefore, although based on low-certainty evidence overall, findings suggest that cost implications with these different techniques may be negligible.
Equity
No research evidence was found.
Additional considerations
Encouraging women to use their own natural, physiological method of pushing in the second stage might help women to feel more in control of their childbirth experience and empower them to enjoy their reproductive rights.
Acceptability
A qualitative systematic review of women’s experiences of labour and childbirth (26) found no direct evidence relating to women’s views on pushing. Indirect evidence from this review suggests that in certain LMIC contexts women are more likely to experience disrespectful or abusive care when health care professionals adopt a directive approach to labour and childbirth (low confidence in the evidence). Findings also indicate that women like to feel “in control” of labour progress but welcome support and advice from reassuring health care professionals, provided it is consistent, coherent and in accord with their perceived physiological and psychological state (low confidence in the evidence).
The qualitative systematic review found no direct evidence on health care professionals’ views relating to pushing (26).
Additional considerations
Evidence from a review and case analysis study indicates that women do not like the conflicting internal and external messages, when their internal desire is to push but health care professionals tell them not to, or vice versa (161).
Feasibility
A qualitative systematic review of women’s
experiences of labour and childbirth found no direct evidence relating to women’s views on pushing (26). Indirect evidence would suggest that there are unlikely to be any concerns around feasibility.
3. EVIDENCE AND RECOMMENDATIONS
The qualitative systematic review found no direct evidence on health care professionals’ views relating to pushing (26). Indirect evidence would suggest that organizational pressures relating to time and bed space may encourage health care professionals to favour directed pushing in certain contexts based on the perception that it shortens labour (very low confidence in the evidence).
Additional considerations
The teaching of women, by health care professionals, to follow their own instincts to push when they feel the urge is more feasible than teaching women to perform the Valsalva manoeuvre.
Table 3.51 Summary of judgements: Spontaneous pushing compared with directed pushing
Desirable
effects –
Don’t know –
Varies ✓
Trivial –
Small –
Moderate –
Large Undesirable
effects –
Don’t know –
Varies –
Large –
Moderate –
Small ✓
Trivial Certainty of
the evidence –
No included studies
Very low– ✓
Low –
Moderate –
High
Values –
Important uncertainty or
variability
Possibly – important uncertainty or
variability
Probably no ✓ important uncertainty or
variability
No important – uncertainty or variability Balance of
effects –
Don’t know –
Varies –
Favours the comparison
Probably – favours directed pushing
Does not ✓ favour spontaneous
or directed pushing
Probably – favours spontaneous
pushing
Favours – spontaneous
pushing
Resources
required –
Don’t know –
Varies –
Large costs –
Moderate costs
Negligible ✓ costs or savings
Moderate – savings
Large savings–
Certainty of evidence of required resources
No included ✓ studies
Very low– –
Low –
Moderate –
High
Cost-effectivenessa –
Don’t know –
Varies –
Favours the comparison
Probably – favours directed pushing
Does not – favour spontaneous
or directed pushing
Probably – favours spontaneous
pushing
Favours – spontaneous
pushing
Equity ✓
Don’t know –
Varies –
Reduced –
Probably reduced
Probably no – impact
Probably – increased
Increased–
Acceptability –
Don’t know –
Varies –
No –
Probably No ✓
Probably Yes –
Yes
Feasibility –
Don’t know –
Varies –
No –
Probably No ✓
Probably Yes –
Yes
a The cost-effectiveness domain was not judged because the desirable effects of the intervention were trivial.
WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE
3.3.5 Method of pushing for women with epidural analgesia