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Birth position for women without epidural analgesia RECOMMENDATION 34

Summary of the main findings for comparison 2

3.3 Second stage of labour

3.3.2 Birth position for women without epidural analgesia RECOMMENDATION 34

3. EVIDENCE AND RECOMMENDATIONS

3.3.2 Birth position for women without epidural analgesia

WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE

however, on sensitivity analysis, low-certainty evidence suggests that upright positions may have little or no effect on third- or fourth-degree tears (3 trials, 872 women, RR 1.46, 95% CI 0.44–4.79).

Maternal morbidity: Low-certainty evidence suggests that an upright position may increase estimated blood loss greater than 500 mL (15 trials, 5615 women, RR 1.48, 95% CI 1.10–1.98; absolute risk difference: 21 more per 1000 [from 4 to 43 more]). On sensitivity analysis, the certainty of this evidence increased to moderate.

Pain intensity: Low-certainty evidence on maternal pain suggests that there may be little or no

difference in pain in the second stage of labour with an upright position, as measured with a visual analogue scale (1 trial, 155 women, MD 0.32 higher, 95% CI 0.16 lower to 0.8 higher), or postpartum pain (1 trial, 155 women, MD 0.48 lower, 95% CI 1.28 lower to 0.32 higher). Further evidence on pain intensity measured in one trial (90 women) is of very low certainty. Low-certainty evidence suggests that there may be little or no difference in analgesia requirements during the second stage (7 trials, 3093 women, RR 0.97, 95% CI 0.93–1.02).

Birth experience: The review did not report on birth experience outcomes.

Fetal and neonatal outcomes

Perinatal hypoxia-ischaemia: The review did not report 5-minute Apgar score less than 7, cord blood acidosis, or hypoxic-ischaemic encephalopathy (HIE) outcomes.

Fetal distress: Moderate-certainty evidence suggests that upright positions are probably associated with fewer abnormal FHR patterns (2 trials, 617 babies, RR 0.46, 95% CI 0.22–0.93).

Perinatal mortality: Low-certainty evidence suggests that there may be little or no difference in perinatal mortality with upright positions (4 trials, 982 babies, RR 0.79, 95% CI 0.51–1.21) (155).

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 OASI risk 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 OASI risk in parous women but not in nulliparous women.

Overall, 57% of nulliparous women and 26% of

parous women underwent epidural analgesia in this study and findings were not reported separately according to its use.

A 2013 Cochrane systematic review found that the duration of labour with upright and ambulant positions compared with recumbent positions and bed care for the first stage of labour is probably about 1 hour and 22 minutes shorter (15 trials, 2503 women average MD -1.36 hours, 95% CI -2.22 to -0.51) (155). Findings also suggest that upright positions in the first stage probably reduce caesarean section (14 trials, 2682 women, RR 0.71, 95% CI 0.54–0.94) and epidural use (9 trials, 2107 women, RR 0.81, 95% CI 0.66–0.99). These effects did not occur in a comparison involving women with epidural analgesia.

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 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 expect labour and childbirth to be painful but they 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).

Resources

No research evidence on resources was found.

Additional considerations

Evidence on effects suggests that upright birth positions might reduce instrumental vaginal births and episiotomy but might increase second-degree tears and PPH, therefore, the cost-effectiveness is unclear. Health care professionals accustomed to supporting women to give birth in recumbent positions would require training on how to support women to give birth in an upright position. Upright positions do not necessarily require additional props (e.g. birth cushions).

3. EVIDENCE AND RECOMMENDATIONS

Equity

No direct evidence was found on the impact of the different birth positions on equity. However, indirect evidence from a review of barriers and facilitators to facility-based birth indicates that many women have a “fear of cutting” by health workers (e.g. episiotomy and caesarean section) and that this is probably a significant barrier to the uptake of facility-based birth by disadvantaged women in LMICs (moderate confidence in the evidence) (8). Therefore, birth practices that reduce these medical interventions might improve equity.

Additional considerations

Offering women birthing options that include those that are acceptable within their local customs and norms could positively impact on equity, through increasing facility-based births in settings where women generally avoid hospital birth because of the lack of alternative birthing options.

In addition, encouraging upright labour and birth positions in well resourced settings might have a positive impact on equity by reducing unnecessary medical interventions and associated resource use among more advantaged women.

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).

The review also reported findings on health care professionals’ experiences (26), which 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 childbirth process easier for them to manage (moderate confidence in the evidence).

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 childbirth but less than 5% were aware of alternative positions (e.g. squatting, kneeling, and on hands and knees).

Data from the study in Nigeria 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 were sometimes unaware of non-supine positions and felt that different options for birth positions should have been highlighted during antenatal care (low confidence in the findings).

Findings on health care professionals’ experiences from the same systematic review 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 birth rooms prevented women from adopting an upright position (low confidence in the evidence).

Additional considerations

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 Table 3.48 Main resource requirements for upright birth positions

Resource Description

Staff  Midwives/nurses/doctors: same as for recumbent birth positions Training  In-service training to support upright birth positions

Supplies  Usual supplies

Equipment  Bed: same as for recumbent positions



 Birthing cushion or other options to support upright birth (optional) Infrastructure  Birthing room with space to accommodate a birthing stool (optional) Supervision and

monitoring  Good access to medical supervision: same as for recumbent birth positions

WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE

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.

Table 3.49 Summary of judgements: Upright birth positions for women without epidural analgesia compared with recumbent birth positions

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 recumbent

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-effectiveness

Don’t know

Varies

Favours recumbent

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

3. EVIDENCE AND RECOMMENDATIONS

3.3.3 Birth position for women with epidural analgesia