Randomised trial comparing the upright and supine positions for the second stage of labour. Influence of the position of the mother at delivery over some maternal and neonatal outcomes. A prospective randomised trial on the effect of position in the passive second stage of labour on birth outcome in nulliparous women using epidural analgesia. Effect of delayed supine positioning after induction of spinal anaesthesia for caesarean section. Upright position during the first stage of labor: a randomised controlled trial. Upright posture and the efficiency of labour. Active versus expectant management of third stage of labour: the Hinchingbrooke randomised controlled trial. Combined spinal epidural anaesthesia for caesarean section: a randomised comparison of Oxford, lateral and sitting positions. Randomized trial of amniotomy in labour versus the intention to leave membranes intact until the second stage. A randomized controlled trial of prophylactic maneuvers to reduce head-to-body delivery time in patients at risk for shoulder dystocia. Upright versus recumbent position in the second stage of labour in women with combined spinal-epidural analgesia. Hypotension following combined spinal-epidural anaesthesia for Caesarean section. Left lateral position vs. tilted supine position. Maternal cardiovascular consequences of positioning after spinal anaesthesia for Caesarean section: left 15 degree table tilt vs. left lateral.
To assess the maternal and neonatal effects of upright compared with recumbent positions during delivery, in terms of defined outcome variables.
                A randomised controlled trial.
                St Monica's Nursing Home, a midwife based maternity unit in Cape Town, South Africa.
                Five hundred and seventeen women of low obstetrical risk assigned to deliver at the nursing home.
                The trial showed that women who adopted the upright posture for delivery experienced less pain. perineal trauma and fewer episiotomies than those who delivered in the supine position.
                The data suggest that in women of low obstetrical risk, choice of posture during delivery may be encouraged. Evaluate possible advantages or disadvantages of the sitting over the horizontal position during the second stage of labor.
                Clinical trial randomly selecting 127 volunteers for the sitting position and 121 for the horizontal position during the second stage of labor. Duration of the second stage and of expulsion of the placenta, vulvo vaginal and perineal lacerations, blood lost and Apgar score were evaluated.
                There was a non-significant decrease of 3.4 min in the duration of the second period in the vertical position in comparison with the horizontal position. There was a similar difference in the duration of delivery of the placenta, but also non-significant. Blood loss was slightly greater among women delivering in vertical position, but the difference did not reach significance. Breastfeeding did not show any influence on blood loss and on the time for delivering the placenta. The incidence of perineal trauma was 44.1% for vertical position and 47% for horizontal position in the whole group and of 47.8% and 71.2% in the group with history of episiotomy. This last difference was statistically significant. The results of this study are in the line of other studies that suggest some advantages and possible disadvantages of the vertical position.
                Mothers should be given the choice of the posture to be assumed during parturition. The supine position should not be imposed and episiotomy should not be a routine. To determine whether the rate of instrumental birth in nulliparous women using epidural analgesia is affected by maternal position in the passive second stage of labour.
                A pragmatic prospective randomised trial.
                Consultant maternity unit in the Midlands.
                One hundred and seven nulliparous women using epidural analgesia and reaching the second stage of labour with no contraindications to spontaneous birth.
                The lateral versus the supported sitting position during the passive second stage of labour.
                Mode of birth, incidence of episiotomy, and perineal suturing.
                Recruitment was lower than anticipated (107 vs. 220 planned). Lateral position was associated with lower rates of instrumental birth rate (lateral group 33%; sitting group 52%; p=0.05, RR 0.64, CI for RR: 0.40-1.01; Number-needed-to-treat (NNT)=5), of episiotomy (45% vs. 64%; p=0.05, RR 0.66, CI for RR: 0.44-1.00, NNT=5), and of perineal suturing (78% vs. 86%; p=0.243, RR 0.75, CI for RR 0.47-1.17). The odds ratio for instrumental birth in the sitting group was 2.2 (CI 1.00-4.6). Logistic regression of potential confounder variables was undertaken, due to a large variation in maternal weight between the randomised groups. Of the nine possible confounders tested, only position of the baby's head at full dilation affected the risk of instrumental birth significantly (p=0.4, OR 2.7 where the fetal head was in the lateral or posterior position). Maternal weight did not appear to have any effect. The odds ratio for instrumental delivery for women randomised to the sitting position was slightly higher within the logistic regression model (adjusted OR 2.3).
                Women randomised to the lateral position had a better chance of a spontaneous vaginal birth than those randomised to the supported sitting position. Position of the babies head at full dilation had an additional effect on mode of birth. These effects are not conclusively generalizable. RECOMMENDATIONS FOR PRACTICE: The lateral position is likely to be at best beneficial, and at the worst no less harmful than the sitting position for most women and their babies who meet the criteria set for this study. Conclusive evidence for or against the technique should be established using larger trials. The study tested the hypothesis that the incidence of hypotension during spinal anaesthesia for caesarean section is less in parturients who remain in the sitting position for 3 min compared with parturients who are placed in the modified supine position immediately after induction of spinal anesthesia.
                Spinal anaesthesia was induced with the woman in the sitting position using 2.8 ml hyperbaric bupivacaine 0.5% at the L(3-4) or L(2-3) interspace. Ninety-eight patients scheduled for elective caesarean section under spinal anaesthesia were randomised to assume the supine position on an operating table tilted 10 degrees to the left (modified supine position) immediately after spinal injection (group 0, n=52) or to remain in the sitting position for 3 min before they also assumed the modified supine position (group 3, n=46). Isotonic saline 2-300 ml was given intravenously over 15 min before spinal injection followed by 15 ml/kg over 15-20 min after induction of spinal anaesthesia. If the systolic blood pressure decreased to less than 70% of baseline or to less than 100 mmHg or if there was any complaint of nausea, ephedrine was given in 5 mg boluses intravenously every 2 min.
                The blood pressure decreased significantly in both groups following spinal injection (P<0.001). Blood pressure variations over time differed significantly between the two groups (P<0.05). However, the incidence of maternal hypotension before delivery was similar in the two groups. The difference was caused by the time to the blood pressure nadir being significantly shorter in group 0 compared with group 3 (9.1+/-4.5 min vs. 11.7+/-3.7 min, P<0.01). Similar numbers of patients received rescue with ephedrine before delivery: 35 (67%) in group 0 vs. 26 (57%) in group 3 (NS). The mean total dose of ephedrine before delivery was 10.9 mg in group 0 vs. 9.2 mg in group 3 (NS). There were no differences in neonatal outcome between the two groups.
                At elective caesarean section, a 3-min delay before supine positioning does not influence the incidence of maternal hypotension after induction of spinal anaesthesia in the sitting position with 2.8 ml of bupivacaine 0.5% with 8% dextrose. Evaluation of the upright position during the first stage of labor on pain, patient satisfaction, obstetrical and perinatal outcomes in nullipara women.
                This prospective, randomised, controlled trial included a group of 54 women who were informed and encouraged to adopt the upright position, and a control group of 53 women who were not given this information. The difference between groups was evaluated using the chi2, Wilcoxon and Fisher's Exact tests. Significance was defined as p<0.05. Risk ratios and 95% confidence intervals were calculated.
                No statistically significant differences were found between the groups in baseline characteristics, obstetrical and perinatal outcomes; however, there was a preference among women in both groups for the upright position.
                The upright position during the first stage of labor did not contribute towards a shorter duration of labor; however, it proved to be a safe and well-accepted option for the women of this study. The claim that an upright maternal posture during labour improves the efficiency of the uterus to the benefit of both mother and fetus has been investigated in a randomised prospective study. 40 patients undergoing induction of labour were allocated to a recumbent group or an upright group. No differences were found between the groups in the length of labour, mode of delivery, requirements of oxytocic and analgesic drugs, or fetal and neonatal condition. Our data do not support calls to change conventional intrapartum nursing attitudes. This study tested the hypotheses that active management of the third stage of labour lowers the rates of primary postpartum haemorrhage (PPH) and longer-term consequences compared with expectant management, in a setting where both managements are commonly practised, and that this effect is not mediated by maternal posture.
                1512 women judged to be at low risk of PPH (blood loss >500 mL) were randomly assigned active management of the third stage (prophylactic oxytocic within 2 min of baby's birth, immediate cutting and clamping of the cord, delivery of placenta by controlled cord traction or maternal effort) or expectant management (no prophylactic oxytocic, no cord clamping until pulsation ceased, delivery of placenta by maternal effort). Women were also randomly assigned upright or supine posture. Analyses were by intention to treat.
                The rate of PPH was significantly lower with active than with expectant management (51 [6.8%] of 748 vs 126 [16.5%] of 764; relative risk 2.42 [95% CI 1.78-3.30], p<0.0001). Posture had no effect on this risk (upright 92 [12%] of 755 vs supine 85 [11%] of 757). Objective measures of blood loss confirmed the results. There was more vomiting in the active group but no other important differences were detected.
                Active management of the third stage reduces the risk of PPH, whatever the woman's posture, even when midwives are familiar with both approaches. We recommend that clinical guidelines in hospital settings advocate active management (with oxytocin alone). However, decisions about individual care should take into account the weights placed by pregnant women and their caregivers on blood loss compared with an intervention-free third stage. Maternal position during induction of intrathecal anaesthesia for caesarean section influences block height and haemodynamic stability. In a randomised study of 90 women presenting for elective caesarean section using combined spinal-epidural anaesthesia, three positions were compared--the Oxford position (group O), the right lateral to supine wedged (group R) and the sitting to supine wedged (group S). Hyperbaric bupivacaine 12.5 mg with fentanyl 12.5 microg was injected intrathecally using a needle-through-needle CSE technique. Intravenous ephedrine 6 mg was given every minute that systolic blood pressure fell below 80% of baseline. Time required for block height to reach T5 as assessed by light touch, was similar in the three groups. There were no significant differences in blood pressure although ephedrine requirements were less in group R. There were no significant differences in the incidence of maternal nausea and vomiting or in neonatal outcome as assessed by Apgar scores and umbilical cord blood gas analysis. Although the study failed to show any significant differences in block height between the groups, no women in group O had a block above T2 compared with three in group R and three in group S. To compare by randomized prospective clinical trial the outcome of labours which are managed with the intention to leave the membranes intact, compared with the practice of elective artificial rupture of the membranes (ARM) in early established labour.
                Prospective randomized controlled trial of low risk women admitted in spontaneous labour, with intact membranes.
                The labour ward of St. James's University Hospital, Leeds, UK.
                362 women in spontaneous labour with intact membranes and no evidence of fetal distress, between 37 and 42 weeks gestation. During the course of the trial it was found that some randomization cards could not be accounted for and a system of daily checks was instituted. The results were analysed for all recorded women (n = 362) and after institution of the more rigorous system (n = 120).
                The duration of each phase of labour, epidural rate, prevalence of an abnormal cardiotocograph (CTG) (assessed blind), method of delivery and neonatal outcome.
                178 of the 183 women (97%) in the ARM group had their membranes ruptured in early labour, and 83 (46%) of the 179 women allocated to non-intervention had ARM performed at some stage. A significant decrease in the duration of labour (mean 8.3, SD 4.1 h vs mean 9.7, SD 4.8 h, n = 156; P = 0.05) was found amongst primigravidae allocated to ARM when compared with non intervention. The duration of the second stage of labour was unaffected. In the ARM group the epidural rate was higher and labour was more often complicated by CTG abnormalities. There were no differences in the method of delivery, fetal condition at birth (cord blood lactate, Apgar score) or postpartum pyrexia between the ARM and non-intervention groups. The same trends were observed when analysis was confined to women entered into the trial after the system of rigour was instituted.
                Routine ARM results in labour that is slightly shorter than if the membranes are allowed to rupture spontaneously but more epidurals are used suggesting that labour is more painful. There are fewer fetal heart rate abnormalities if the membranes are left intact but amniotomy has no effect on fetal condition at birth. To assess whether prophylactic use of the McRoberts maneuver and suprapubic pressure decreased the head-to-body time, as a proxy for shoulder dystocia, in at-risk patients.
                Patients with estimated fetal weights over 3800 g were randomized to undergo the McRoberts maneuver and suprapubic pressure before delivery of the fetal head (prophylactic maneuvers) or to undergo maneuvers only after delivery of the head, if necessary (controls). A total of 185 patients were enrolled in the study. After exclusions (eg, abdominal delivery), there were 128 evaluable vaginal deliveries. The study had the power to detect a 30% difference in head-to-body time between groups.
                Head-to-body delivery times did not differ between the prophylactic and control patients (24 +/- 18 seconds versus 27 +/- 20 seconds, P =.38). In addition, the two groups did not differ in rates of admission of the infant to the special care nursery or in birth injuries. There was a significant increase in the risk of delivering by cesarean for patients randomized to the use of prophylactic maneuvers.
                This study does not support the hypothesis that prophylactic use of the McRoberts maneuver and suprapubic pressure speeds delivery in a population of patients at increased risk for shoulder dystocia. Neuraxial blockade is widely used for pain relief in labour. This form of analgesia may be associated with an increase in instrumental delivery rates due to dystocia. 'Traditional' epidurals cause motor blockade and hence immobility. Using a low dose anaesthetic-opioid combination with either epidural or combined spinal-epidural, selective sensory blockade can be achieved, allowing mobility as well as pain relief. In this study, we randomised women with combined spinal-epidural analgesia either to mobilise (upright group n = 25) or to remain recumbent (n = 41) in the second stage of labour. We found women in the upright group had significantly shorter total second stage, (132 vs 109 min,P = 0.019) particularly during the pushing phase (73 vs 51 min, P = 0.011). Although there were fewer instrumental deliveries in the upright group, this was not statistically significant. Women who were randomised to the upright group, did actually mobilise. We conclude that mobilisation in the second stage of labour is possible, and may reduce the length of the second stage. Eighty-seven pregnant mothers undergoing elective Caesarean section were randomly allocated either to the full left lateral position (n = 45) or to the supine position with 12 degrees left lateral tilt (n = 42) after a combined spinal-epidural (CSE) in the sitting position and an initial 2 min in the full right lateral position. Fewer mothers were hypotensive while in the study position [29 (64%) in lateral group vs. 38 (90%) in the tilted supine group; p = 0.03]. Mothers in the lateral group tended to become hypotensive after turning them back to the tilted supine position immediately before surgery; hence the number of mothers who were hypotensive from the insertion of the CSE until delivery were similar [36 (80%) vs. 38 (90%)]. Mothers in the lateral group needed a lower dose of ephedrine to treat their hypotension while in their study position (median (interquartile range [range]) 6 (0-12 [0-36]) mg vs. 12 (6-18 [0-36]) mg, respectively; p = 0.04) but ephedrine requirements were similar overall (12 (6-12 [0-36]) mg vs. 12 (6-18 [0-36]) mg), respectively. The full left lateral position reduces the incidence of early hypotension compared with the tilted supine position with tilt, and makes it easier to treat. Sixty healthy women undergoing elective Caesarean section were randomly allocated to either a measured 15 degrees left table tilt position (n = 31) or full left lateral position (n = 29) for a 15-min period after spinal blockade. Arm and leg blood pressure, ephedrine requirements, symptoms, fetal heart rate, cord gases and Apgar scores were recorded. Mean ephedrine requirements and incidence of hypotension were similar in the two groups. Arm systolic arterial pressure over time was similar in both groups, but leg systolic arterial pressure over time was significantly lower in the tilt group (p < 0.001); the mean leg systolic arterial pressure was lower for all 15 sequential recordings in the tilt group, reaching statistical significance (p < 0.05) at 4, 5, 6 and 8 min. Differences in maternal nausea, vomiting and bradycardia and fetal outcome were not statistically significant. Following spinal anaesthesia, even a true 15 degrees left table tilt position is associated with aortic compression.
The findings of this review suggest several possible benefits for upright posture in women without epidural, but with the possibility of increased risk of blood loss greater than 500 mL. Until such time as the benefits and risks of various delivery positions are estimated with greater certainty, when methodologically stringent data from trials are available, women should be allowed to make choices about the birth positions in which they might wish to assume for birth of their babies.