Alternative positions in the second stage of labour: a randomized controlled trial. Maternal position, labor, and comfort. Upright position during the first stage of labor: a randomised controlled trial. Upright posture and the efficiency of labour. Lack of effect of walking on labor and delivery. Randomised trial comparing the upright and supine positions for the second stage of labour. Maternal half-sitting position in the second stage of labor. Randomised controlled trial of effect of hands and knees posturing on incidence of occiput posterior position at birth. Effects of sitting position on uterine activity during labor.
A controlled clinical trial involving 151 primigravidae and 18 midwives assessed the acceptability and outcome of second-stage labour in upright positions. Women who had no specific antenatal preparation and preferences regarding labour positions were managed either conventionally (semi-recumbent and lateral), or encouraged to adopt upright positions (squatting, kneeling, sitting or standing) according to individual preference. Of the women allocated to the upright position 74% completed the second stage upright, with kneeling being the most favoured position, but squatting was, despite all assistance, too difficult to maintain. Adoption of upright positions resulted in a higher rate of intact perineums. There was a clinically apparent reduction of forceps deliveries in the upright group which influenced midwives' attitudes. Moving the parturient from recumbent to upright positions was often perceived to be beneficial when there was slow progress. Estimated blood loss was similar in the two groups, as was the condition of the newborn (Apgar score and umbilical artery pH). Alternative positions in the second stage of labour, in particular kneeling, are achievable even without specific birth aids and antenatal preparation. They appear safe, acceptable to most parturients and their midwives, and are easily integrated into modern labour ward practice; they may have clinical advantages which need further investigation. The purpose of this study was to determine if women who assumed upright positions during the phase of maximum slope would have a shorter phase of maximum slope in their labor and experience more comfort than women who assumed recumbent positions. Forty laboring women were randomly assigned to either an upright or recumbent position group. Subjects assumed the positions of their assigned group during the phase of maximum slope in their labor (cervical dilatation from 4 cm to 9 cm). Every hour during the phase of maximum slope, each subject was examined vaginally to determine her cervical dilatation and assessed for her level of comfort using the Maternal Comfort Assessment Tool. Women in the upright position group had a significantly shorter phase of maximum slope in labor, but did not significantly differ in comfort level from women in the recumbent group. Newborn Apgar scores were not significantly different between the two groups. Nurses need to be aware that the upright labor positions have the distinct advantages of facilitating efficient uterine contractions and reducing the duration of the phase of maximum slope in labor, with no increase in the discomfort experienced or adverse effect on newborn well-being. 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. Walking during labor may reduce patients' discomfort and improve outcomes. We conducted a randomized trial of walking during active labor to determine whether it altered the duration of labor or other maternal or fetal outcomes. Women with uncomplicated pregnancies between 36 and 41 weeks' gestation and in active labor were randomly assigned either to walking or to no walking (usual care). Pedometers were used to quantify walking, and the time spent walking was recorded.
                Of the 536 women assigned to the walking group, 380 actually walked. Their mean (+/-SD) walking time was 56+/-46 minutes. There were no significant differences between the women assigned to the walking group and the 531 women assigned to the usual-care group in the duration of the first stage of labor (6.1 hours in both groups, P=0.83), the need for labor augmentation with oxytocin (23 percent vs. 26 percent, P=0.25), and the use of analgesia (84 percent vs. 86 percent, P=0.59). Similarly, the percentages of women requiring delivery by forceps (4 percent vs. 3 percent, P=0.35) and cesarean section (4 percent vs. 6 percent, P=0.25) were not significantly different. These labor and delivery outcomes were unrelated to walking in both nulliparous and parous women. The infants' outcomes were also similar in the two study groups.
                Walking neither enhanced nor impaired active labor and was not harmful to the mothers or their infants. 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. The maternal half-sitting and supine position during the second stage of fullterm labor was compared in 100 women who, after identical opening phases in supine position, randomly delivered in half-sitting (50 degrees, n = 50) or supine position (n = 50). The whole duration of the second stage of labor or the time spent in active pushing did not differ between the groups. Vacuum extraction was needed twice (4%) in the group delivering in half-sitting and six times (12%) in the group delivering in supine position. Vaginal tear occurred in one mother in both groups. Early decelerations in fetal cardiotocography were seen 22 times in half-sitting and 14 times in supine group (p less than 0.05). However, late decelerations were seen in only one mother with half-sitting, as compared to five mothers with supine position. Four infants of mothers giving birth in supine position had 1 minute APGAR scores 7 or less, whereas all infants of mothers delivering in half-sitting position had APGAR scores higher than 7. Subjectively the mothers liked more the half-sitting position. We conclude that a women can deliver in half-sitting position without maternal or fetal risks. To evaluate the efficacy of hands and knees position and pelvic rocking exercises on the incidence of fetal occiput posterior position at birth.
                Multicentre randomised controlled trial.
                Seven maternity units in New South Wales, Australia, encompassing teaching hospitals and district general hospitals.
                2547 pregnant women at 37 weeks' gestation; 1292 randomised to the intervention group and 1255 to the control group.
                Hands and knees position and pelvic rocking exercises from 37 weeks' gestation until the onset of labour.
                Incidence of fetal occiput posterior position at birth.
                1046 women in the intervention group and 1209 women in the control group remained in the study until they went into labour. No significant difference existed between the groups for the incidence of occiput posterior position at birth: 105 (8.1%) women in the intervention group and 98 (7.8%) in the control group had a baby in a posterior position at delivery (difference in risk 0.3%, 95% confidence interval -1.8 to 2.4). The incidence of fetal transverse arrest was 3.4% (44 women) in the intervention group and 3.0% (38 women) in the control group (difference in risk 0.4, -1 to 1.7). No differences occurred between intervention and control groups for induction of labour, use of epidural, duration of labour, mode of delivery, use of episiotomy, or Apgar score.
                Hands and knees exercise with pelvic rocking from 37 weeks' gestation to the onset of labour did not reduce the incidence of persistent occiput posterior position at birth. To determine which components of uterine activity are affected by different positions of labor, 116 intrauterine pressure records in the sitting and supine positions were analyzed in order to measure resting, contraction, and bearing down pressures. The resting pressure in the sitting position showed consistent elevation compared to the supine position, while the contraction pressure did not differ strikingly in the two positions. The bearing down pressure in the sitting position for nulliparas during the second stage and for multiparas at the time of the 8- to 10-cm dilation was significantly higher than that in the supine position. Also, the sitting position led to a significantly shorter duration of the second stage in nulliparas and the 5- to 10-cm dilation period in multiparas. These findings suggest that the maternal position does not affect uterine contractility, that the increased resting pressure in the sitting position is of some importance in supplementing the downward delivery force, and that the increased bearing down pressure in the sitting position could help to significantly shorten the duration of labor.
There is evidence that walking and upright positions in the first stage of labour reduce the length of labour and do not seem to be associated with increased intervention or negative effects on mothers' and babies' wellbeing. Women should be encouraged to take up whatever position they find most comfortable in the first stage of labour.