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

Marion Kibuka, Jim G Thornton

Epidural analgesia for pain relief in labour prolongs the second stage of labour and results in more instrumental deliveries. It has been suggested that a more upright position of the mother during all or part of the second stage may counteract these adverse effects. This is an update of a Cochrane review first published in 2013. To assess the effects of different birthing positions (upright and recumbent) during the second stage of labour, on important maternal and fetal outcomes for women with epidural analgesia. We searched Cochrane Pregnancy and Childbirth's Trials Register (19 September 2016) and reference lists of retrieved studies. All randomised or quasi-randomised trials including pregnant women (either primigravidae or multigravidae) in the second stage of induced or spontaneous labour receiving epidural analgesia of any kind. Cluster-RCTs would have been eligible for inclusion in this review but none were identified. Studies published in abstract form only were eligible for inclusion.We assumed the experimental type of intervention to be the maternal use of any upright position during the second stage of labour, compared with the control intervention of the use of any recumbent position. Two review authors independently assessed trials for inclusion, assessed risk of bias, and extracted data. Data were checked for accuracy. We contacted study authors to try to obtain missing data. Five randomised controlled trials, involving 879 women, comparing upright positions versus recumbent positions were included in this updated review. Four trials were conducted in the UK and one in France. Three of the five trials were funded by the hospital departments in which the trials were carried out. For the other three trials, funding sources were either unclear (one trial) or not reported (two trials). Each trial varied in levels of bias. We assessed all the trials as being at low or unclear risk of selection bias. None of the trials blinded women, staff or outcome assessors. One trial was poor quality, being at high risk of attrition and reporting bias. We assessed the evidence using the GRADE approach; the evidence for most outcomes was assessed as being very low quality, and evidence for one outcome was judged as moderate quality.Overall, we identified no clear difference between upright and recumbent positions on our primary outcomes of operative birth (caesarean or instrumental vaginal) (average risk ratio (RR) 0.97; 95% confidence interval (CI) 0.76 to 1.29; five trials, 874 women; I² = 54% moderate-quality evidence), or duration of the second stage of labour measured as the randomisation-to-birth interval (average mean difference -22.98 minutes; 95% CI -99.09 to 53.13; two trials, 322 women; I² = 92%; very low-quality evidence). Nor did we identify any clear differences in any other important maternal or fetal outcome, including trauma to the birth canal requiring suturing (average RR 0.95; 95% CI 0.66 to 1.37; two trials; 173 women; studies = two; I² = 74%; very low-quality evidence), abnormal fetal heart patterns requiring intervention (RR 1.69; 95% CI 0.32 to 8.84; one trial; 107 women; very low-quality evidence), low cord pH (RR 0.61; 95% CI 0.18 to 2.10; one trial; 66 infants; very low-quality evidence) or admission to neonatal intensive care unit (RR 0.54; 95% CI 0.02 to 12.73; one trial; 66 infants; very low-quality evidence). However, the CIs around each estimate were wide, and clinically important effects have not been ruled out. Outcomes were downgraded for study design, high heterogeneity and imprecision in effect estimates.There were no data reported on blood loss (greater than 500 mL), prolonged second stage or maternal experience and satisfaction with labour. Similarly, there were no analysable data on Apgar scores, and no data reported on the need for ventilation or for perinatal death. There are insufficient data to say anything conclusive about the effect of position for the second stage of labour for women with epidural analgesia. The GRADE quality assessment of the evidence in this review ranged between moderate to low quality, with downgrading decisions based on design limitations in the studies, inconsistency, and imprecision of effect estimates.Women with an epidural should be encouraged to use whatever position they find comfortable in the second stage of labour.More studies with larger sample sizes will need to be conducted in order for solid conclusions to be made about the effect of position on labour in women with an epidural. Two studies are ongoing and we will incorporate the results into this review at a future update.Future studies should have the protocol registered, so that sample size, primary outcome, analysis plan, etc. are all clearly prespecified. The time or randomisation should be recorded, since this is the only unbiased starting time point from which the effect of position on duration of labour can be estimated. Future studies might wish to include an arm in which women were allowed to choose the position in which they felt most comfortable. Future studies should ensure that both compared positions are acceptable to women, that women can remain in them for most of the late part of labour, and report the number of women who spend time in the allocated position and the amount of time they spend in this or other positions.