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research findings favor the sitting position for delivery

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Effects of using sitting position versus lithotomy position during the second stage of labour on maternal and neonatal outcomes and the childbirth experience of chinese women: a prospective cohort study.

research findings favor the sitting position for delivery

1. Introduction

2. materials and methods, 2.1. study design and participants, 2.2. study variables, 2.3. data collection, 2.4. statistical analysis, 3.1. demographic and clinical characteristics of participants, 3.2. comparison of the primary and secondary outcomes of childbirth between cohorts, 4. discussion, strengths and limitations, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, acknowledgments, conflicts of interest.

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Click here to enlarge figure

VariablesTotal n (%)
N = 222
Sitting-Birth Cohort n (%)
N = 106
Supine-Birth Cohort n (%)
N = 116
222106116
Primipara183 (82.4)91 (85.8)92 (79.3)
Multipara39 (17.6)15 (14.2)24 (20.7)
30.97 ± 2.6630.67 ± 2.5539.75 ± 0.94
Primipara30.48 ± 2.5730.26 ± 2.4630.68 ± 2.68
Multipara33.31 ± 1.6033.13 ± 1.5533.42 ± 1.66
Primipara1839192
     High school or below1 (0.5)0 (0)1 (1.1)
     Bachelor’s or junior college99 (54.1)52 (57.1)47 (51.1)
     Master’s or doctorate83 (45.4)39 (42.9)44 (47.8)
Multipara391524
     High school or below1 (2.6)0 (0)1 (4.2)
     Bachelor’s or junior college21 (53.8)8 (53.3)13 (54.2)
     Master’s or doctorate17 (43.6)7 (46.7)10 (41.7)
39 ± 0.9739 ± 1.4239 ± 0.94
Primipara39 ± 0.9839 ± 1.0439 ± 0.92
Multipara39 ± 0.8939 ± 0.7639 ± 0.97
2 (0.9)0 (0)2 (1.7)
Primipara0 (0)0 (0)0 (0)
Multipara2 (0.9)0 (0)2 (8.3)
21.51 ± 2.8321.57 ± 2.9921.46 ± 2.69
Primipara21.50 ± 2.9121.45 ± 3.0921.55 ± 2.73
Multipara21.58 ± 2.4422.30 ± 2.1821.13 ± 2.53
14.02 ± 7.5813.32 ± 6.6614.66 ± 8.31
Primipara14.02 ± 7.0913.13 ± 4.3214.89 ± 8.98
Multipara14.03 ± 9.6514.47 ± 14.5313.75 ± 5.01
Primipara1839192
     LOA139 (76.0)74 (81.3)65 (70.7)
     ROA44 (24.0)17 (18.7)27 (29.3)
Multipara391524
     LOA35 (89.7)13 (86.7)22 (91.7)
     ROA4 (10.3)2 (13.3)2 (8.3)
94 (42.3)44 (41.5)50 (43.1)
Primipara1839192
     Yes82 (44.8)40 (44.0)42 (45.7)
     No 101 (55.2)51 (56.0)50 (54.3)
Multipara391524
     Yes12 (30.8)4 (26.7)8 (33.3)
     No 27 (69.2)11 (73.3)16 (66.7)
142 (64.0)68 (64.2)74 (63.8)
Primipara1839192
     Yes127 (69.4)60 (65.9)67 (72.8)
     No 56 (30.6)31 (34.1)25 (27.2)
Multipara391524
     Yes15 (38.5)8 (53.3)7 (29.2)
     No 24 (61.5)7 (46.7)17 (70.8)
49.68 ± 1.5649.42 ± 1.7149.93 ± 1.36
Primipara49.67 ± 1.3849.53 ± 1.4049.80 ± 1.36
Multipara49.77 ± 2.2348.73 ± 2.9850.42 ± 1.28
3255.18 ± 352.233215.85 ± 360.683291.12 ± 341.94
Primipara 3220.82 ± 340.173187.58 ± 333.633253.70 ± 345.18
Multipara3416.41 ± 367.353387.33 ± 472.623434.58 ± 293.42
     Freestyle position187 (84.6)93 (87.7)94 (81.7)
     upright1 (0.5)1 (0.9)0
     Supine 33 (14.9)12 (11.3)21 (18.3)
     Missing 101
     Yes152 (68.5)79 (74.5)73 (62.9)
     No70 (31.5)27 (25.5)43 (37.1)
VariablesPrimiparous WomenMultiparous Women
Sitting-Birth Cohort n (%) N = 91Supine-Birth Cohort n (%) N = 92χ t/ZpSitting-Birth Cohort n (%) N = 15Supine-Birth Cohort n (%) N = 24χ t/Zp
Duration of second stage (min) ME IQR50.00 (47)76.00 (61) −3.657 0.000NSNS NS
Duration of first stage (min) ME IQR395.00 (213)370.00 (295) −747 0.455NSNS NS
Duration of first and second stage (min) M ± SDNSNS NS246.67 ± 112.17347.04 ± 216.88 −1.654 0.107
Birth modeN = 91N = 9211.623 0.001N = 15N = 24 NS
     Spontaneously85 (93.4)69 (75.0) 15 (100)24 (100)
     Vaginal midwifery6 (6.6)23 (25.0) 00
     CS0 (0)0 (0)
Perineal injuriesN = 70N = 491.320 0.725N = 14N = 232.939 0.230
     Complete10 (14.3)5 (10.2) 2 (14.3)9 (39.1)
     First degree33 (47.1)23 (46.9) 9 (64.3)9 (39.1)
     Second degree26 (37.1)21 (42.9) 3 (21.4)5 (21.7)
     Three/third degree1 (1.4)0 (0) 0(0)0(0)
EpisiotomyN = 91N = 9211.263 0.001N = 15N = 240.119 0.731
     Yes21 (23.1)43 (46.7) 1 (6.7)1 (4.2)
     No70 (76.9)49 (53.3) 14 (93.3)23 (95.8)
Postpartum 2h-haemorrhage 0.201 0.654 2.514 0.113
     <500 mL82 (90.1)81 (88.0) 12 (80)23 (95.8)
     ≥500 mL9 (9.9)11 (12.0) 3 (20)1 (4.2)
     Apgar
     <7 at 1, 5, 10 min0 (0)0 (0) 0 (0)0 (0)
     Cord artery pH
     <7.000 (0)0 (0) 0 (0)0 (0)
     Missing15
VariablesPrimiparous WomenMultiparous Women
Sitting-Birth Cohort
N = 91
Supine-Birth Cohort
N = 92
t/ZpSitting-Birth Cohort
N = 15
Supine-Birth Cohort
N = 24
t/Zp
CEQ, M ± SD3.26 ± 0.352.94 ± 0.445.421 0.0003.34 ± 0.423.09 ± 0.371.842 0.074
Dimensions_1 Professional support3.59 ± 0.443.28 ± 0.63−3.337 0.0013.56 ± 0.463.48 ± 0.51−0.333 0.739
Dimensions_2
Self-ability
3.15 ± 0.452.81 ± 0.544.601 0.0003.33 ± 0.483.02 ± 0.471.953 0.059
Dimensions_3
Self-perception
2.92 ± 0.472.54 ± 0.554.955 0.0003.14 ± 0.682.64 ± 0.382.581 0.019
Dimensions_4
Sense of participation
3.28 ± 0.553.05 ± 0.49−3.512 0.0003.19 ± 0.553.10 ± 0.580.492 0.626
VariablesPrimiparous Women
Lithotomy PositionB/B (95%CI)Adjusted OR (95% CI)p
Duration of second stage (min) ME IQR Reference19.271 (8.535, 30.007)NS0.001
Duration of first stage (min) ME IQR Reference36.768 (−22.268, 95.804)NS0.221
CEQ scores Reference−0.278 (−0.395, −0.160)NS0.000
Birth mode Reference−1.3370.252 (0.092, 0.694)0.008
Perineal injuries Reference
     CompleteReference0.3611.435 (0.426, 4.832)0.560
     First degreeReference0.0891.093 (0.499, 2.397)0.824
     Second degreeReference−0.2850.752 (0.343, 1.651)0.478
Episiotomy Reference−1.0290.357 (0.181, 0.706)0.003
Postpartum 2h-haemorrhage Reference−0.1100.896 (0.319, 2.518)0.835
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Share and Cite

Fu, L.; Huang, J.; Li, D.; Wang, H.; Xing, L.; Wei, T.; Hou, R.; Lu, H. Effects of Using Sitting Position versus Lithotomy Position during the Second Stage of Labour on Maternal and Neonatal Outcomes and the Childbirth Experience of Chinese Women: A Prospective Cohort Study. Healthcare 2023 , 11 , 2996. https://doi.org/10.3390/healthcare11222996

Fu L, Huang J, Li D, Wang H, Xing L, Wei T, Hou R, Lu H. Effects of Using Sitting Position versus Lithotomy Position during the Second Stage of Labour on Maternal and Neonatal Outcomes and the Childbirth Experience of Chinese Women: A Prospective Cohort Study. Healthcare . 2023; 11(22):2996. https://doi.org/10.3390/healthcare11222996

Fu, Li, Jing Huang, Danxiao Li, Huide Wang, Lili Xing, Tao Wei, Rui Hou, and Hong Lu. 2023. "Effects of Using Sitting Position versus Lithotomy Position during the Second Stage of Labour on Maternal and Neonatal Outcomes and the Childbirth Experience of Chinese Women: A Prospective Cohort Study" Healthcare 11, no. 22: 2996. https://doi.org/10.3390/healthcare11222996

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A randomized study of the sitting position for delivery using a newly designed obstetric chair

Affiliation.

  • 1 Department of Obstetrics and Gynaecology, Northern General Hospital, Sheffield.
  • PMID: 2785402
  • DOI: 10.1111/j.1471-0528.1989.tb02393.x

A new obstetric chair has been designed to overcome some of the problems of those currently available commercially. The chair has been used to assess the effects of the sitting position in the second stage of labour on the outcome of delivery in 304 women randomly allocated to be delivered either in the chair or in the conventional dorsal position. Delivery in the chair conferred no benefits to mother or baby and resulted in greater mean blood loss and a higher rate of postpartum haemorrhage.

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  • Published: 13 November 2018

What influences women’s movement and the use of different positions during labour and birth: a systematic review protocol

  • Helen L. Watson   ORCID: orcid.org/0000-0002-5479-8527 1 &
  • Alison Cooke 2  

Systematic Reviews volume  7 , Article number:  188 ( 2018 ) Cite this article

5222 Accesses

Metrics details

Women want to give birth in a safe and supportive environment where they are free to move and adopt different positions. Moving freely and using different positions in labour results in a range of physical and psychological benefits for women. However, many women report that they are restricted from moving freely during labour and birth and it is important to understand the factors that are influencing this.

A mixed-methods systematic review will be undertaken. Qualitative, quantitative and mixed-methods primary empirical studies will be identified by systematically searching seven electronic databases using a search strategy that includes medical subject headings (MeSH) and keywords to cover synonyms and related terms. In addition, reference-tracking will be undertaken, and expert researchers will be contacted to locate relevant studies. Two reviewers will be involved in the assessment of the studies against eligibility criteria, formal quality appraisal and data extraction. A results-based convergent synthesis will be undertaken, using narrative synthesis if the quantitative data are too heterogeneous for meta-analysis, meta-ethnography for the synthesis of the qualitative data and the production of a line of argument synthesis. Finally, confidence in the findings will be formally assessed and conclusions drawn.

The findings of this review will allow researchers, practitioners and policy makers to better understand the factors influencing women’s movement and the use of different positions during labour and birth. This will inform future research and the development of maternity services designed to implement best-evidence concerning movement and positioning during labour and birth into clinical practice.

Systematic review registration

In accordance with the PRISMA-P guidelines (Moher et al. Syst Rev 4:1, 2015), the systematic review protocol was registered with the International Prospective Register of Systematic reviews (PROSPERO) on July 17, 2018 (CRD42018103354).

Peer Review reports

The recently published World Health Organization (WHO) recommendations regarding intrapartum care for a positive childbirth experience [ 1 ] highlight that women want to give birth in a safe and supportive environment where they are free to move and adopt different positions. There is a large body of evidence which demonstrates that freedom to move and adopt upright positions in labour results in a range of physical and psychological benefits for women, including reduced risk of caesarean section, increased agency and sense of control during labour and increased satisfaction with the birth experience [ 2 , 3 ].

Restricting women’s movement during labour and preventing women from adopting comfortable positions is described within a group of poor healthcare professional behaviours constituting disrespect, abuse and mistreatment during maternity care [ 4 ]. This is widely criticised as contravening childbearing women’s rights to be treated with dignity, to be free from harm and ill treatment and to have their choices and preferences respected [ 5 ].

The WHO therefore recommends that women should be encouraged to be mobile and to adopt comfortable positions of their choice, including upright positions, during labour and birth, but emphasises that particular positions should not be forced on women [ 1 ]. However, several recent national surveys have demonstrated that despite national and international guidance and professional governing body recommendations [ 1 , 6 , 7 , 8 , 9 , 10 , 11 , 12 ], large numbers of women across the world continue to give birth lying down with or without their feet in stirrups; 50% in England and Wales [ 13 ], 68% in the United States of America (USA) [ 14 ], 47.9% in Canada [ 15 ] and 92% in Brazil [ 16 ], and significant numbers of women report they are not free to move or change position during some or all of their labour; 30% in England and Wales [ 13 ], 55% in Brazil [ 16 ] and 57% in the USA [ 14 ].

Understanding factors that influence women’s movement and the use of different positions during labour and birth is crucial for the provision of quality, women-centred and human-rights based maternity healthcare services. However, there remains a lack of systematic evidence synthesis concerning this issue.

The review aims to synthesise the evidence concerning women’s freedom of movement and the use of different positions during labour and birth. The review will address the following question:

What factors influence women’s movement and the positions that they adopt during labour and birth?

The protocol has been developed following the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) statement [ 17 ]. The PRISMA-P checklist is included in Additional file  1 . The review protocol has been registered with PROSPERO (CRD42018103354). The enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) statement [ 18 ] has also informed the development of the protocol.

Methodology

The systematic review will apply the principles of mixed-methods research to integrate results from qualitative, quantitative and mixed-methods studies [ 19 ]. The retrieval of qualitative and quantitative data within a review can maximise the usefulness of the synthesis by providing an understanding of human experience alongside empirical evidence about a particular phenomenon [ 20 ], in this case, factors influencing movement and the use of different positions during labour and birth.

Eligibility criteria

Studies will be selected according to the following criteria.

Types of studies

Only peer-reviewed, published, qualitative, quantitative or mixed-methods studies will be included. Review articles will be excluded; however, they will be used to cross check for relevant primary empirical studies. If a review addressing a similar question is identified, the review team will consider relevance and quality when deciding whether to include all previously reviewed studies or to amend the protocol to undertake an update of the review. Conference abstracts will be excluded; however, where the content appears relevant searches for papers reporting the full study will be undertaken including a maximum of two attempts to contact the authors by email. Editorials will be excluded. Studies will be included regardless of length of time of follow-up or length of time since the experience occurred. Studies in any setting will be included. Only studies in English will be included; however, a list of possibly relevant studies in other languages will be provided as an appendix in the final review.

Types of participants

Women of any age experiencing labour and birth in any setting will be included. Women labouring with babies in the breech position will be excluded. Women who are restricted from moving during labour and birth due to pre-existing medical conditions or disabilities will be excluded, as will women who are restrained due to being detained by the state as prisoners or under criminal investigation and women experiencing obstetric emergencies. Studies including heath care providers or women’s family members or birth supporters will also be included if they provide relevant data pertaining to factors influencing women’s movement and positioning during labour and/or birth.

Types of interventions

Whilst this review is not focussing on evidence about interventions, studies investigating interventions will be included if they meet the eligibility criteria.

Types of comparators

Studies do not have to include a comparator to be eligible for inclusion.

Types of outcome measures

Factors influencing maternal movement and/or positions adopted during labour and birth from the perspective of the labouring woman, health professionals, family members or birth supporters will be included.

Information sources

A search strategy will be conducted to identify studies meeting the inclusion criteria. The following electronic databases will be searched to identify relevant studies:

The Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO (1982 onwards)

Medical Literature Analysis and Retrieval System Online (MEDLINE) via Ovid (1946 onwards)

Maternal and Infant Care via Ovid (1971 onwards)

PsycINFO via Ovid (1806 onwards)

Applied Social Sciences Index & Abstracts (ASSIA) via ProQuest (1987 onwards)

International Prospective Register of Systematic reviews (PROSPERO)

African Journals Online (AJOL)

In addition to the electronic database search, the reference lists of eligible studies will be examined to identify any other relevant studies, and midwifery researchers will be contacted via the JISCMail midwifery research email group and asked to identify any further relevant studies.

Search strategy

The development of the search strategy will be an iterative process undertaken by the review team and will include scoping exercises across several databases. The search terms will consist of three broad strings covering population, phenomenon of interest and context [ 21 ]. Medical subject headings (MeSH) and keywords will be used to cover synonyms and related terms, and wildcards and truncation functions will be used to ensure the search is as comprehensive as possible [ 22 , 23 ]. Search terms will be combined using Boolean operators. The search strategy will be developed and agreed by the review team. The MEDLINE search strategy is included in Additional file  2 . The search terms will be adapted to the syntax and subject headings for all other identified databases.

Study records

Data management.

Literature searching will be undertaken by HW, the number of records retrieved from the searches will be recorded, and the citations will be imported into the electronic bibliographic software Endnote X8.2 (Clarivate Analytics).

Selection process

Duplicate records will be removed in Endnote, and the remaining records will be imported into Microsoft Excel and screened against the pre-defined eligibility criteria. One reviewer (HW) will conduct the initial screening based on title and abstract, and the second reviewer will screen 10% of these records. Full-text versions of any records deemed potentially eligible for inclusion by either reviewer will then be screened by two reviewers (HW and 2nd reviewer). Disagreements between the reviewers during the initial or full screening stage will be resolved through discussion or deferral to a third reviewer (AC) if agreement cannot be reached. If there is less than 90% agreement between the two authors during initial screening, then both authors will independently assess all the retrieved records. Reasons for exclusion of studies at the full-text stage will be recorded and provided as an additional file in the final review. A PRISMA diagram [ 24 ] will be provided to show the study search and assessment process.

Quality appraisal

As this review will include qualitative, quantitative and mixed-methods primary studies, the Mixed Methods Appraisal Tool (MMAT) [ 25 ] will be used to appraise the quality of the methods of each included study. This tool includes criteria for all study types and has established content validity [ 26 , 27 ]. Two reviewers (HW and 2nd reviewer) will critically appraise the quality of the included studies; disagreements will be discussed and referred to the third reviewer (AC) if they cannot be resolved. A descriptive summary of the quality of each study will be presented in the final review report, along with an overall quality score calculated using the MMAT scoring metrics and presented as follows: (*) one criterion met to (****) all criteria met [ 25 ]. No studies will initially be excluded on the basis of the quality assessment as it is envisaged that only a small volume of relevant literature will be identified; however, the quality scores will be used to inform the confidence of the review findings (detail is provided in the ‘ Data Synthesis ’ section).

Data extraction will be managed in Microsoft Excel using a data extraction proforma developed specifically for this review which will be piloted by two reviewers (HW and 2nd reviewer) on 2 studies (see Additional file  3 ). Data to be extracted will include publication information, study characteristics, participant information and outcomes [ 28 ]:

Publication information: study title, authors, journal title, year of publication, sources of funding

Study characteristics: aim of study and/or research questions, study type, theoretical perspective, setting, sample size, and methods of sampling, recruitment, data collection and analysis

Participant information: age, number of children, ethnicity, inclusion/exclusion criteria

Outcomes: Factors influencing freedom of movement or the use of different positions during labour or birth

In the case of missing information, one reviewer (HW) will attempt to contact the authors to retrieve this with a maximum of two email attempts. The extracted data will be summarised, tabulated and presented in the final review report. Outcome data will be extracted from sections of the quantitative studies entitled “results” and “findings”. An inclusive approach will be taken with the qualitative studies [ 29 ], whereby outcomes will be extracted from the “findings” or “results” sections of the papers as well as the author interpretations within the discussion/interpretation/conclusion sections of the studies. Qualitative data will be extracted directly into NVivo-11 software (QSR International). Data extraction will be undertaken by the first reviewer (HW), and a second reviewer will assess the accuracy of the extracted data against the original studies. Any disagreements will be discussed and, if not resolved, referred to the third reviewer (AC). In this review, factors influencing freedom of movement or positioning in labour will be considered to be the main outcomes and no other outcomes will be included.

Data synthesis

As this review will comprise data from mixed study methods, a results-based convergent synthesis will be undertaken [ 30 ], based on the segregated method proposed by Sandelowski et al. [ 31 ]. This method is based on the assumptions that qualitative and quantitative studies can be distinguished from each other and that the differences between them justify separate analyses using synthesis methods designed specifically for the data type [ 31 ]. The separate synthesis methods are described below, and once completed, the synthesis products will then be synthesised themselves [ 31 ], by comparing and/or juxtaposing the findings from the qualitative and quantitative evidence [ 30 ] and forming a final line of argument synthesis [ 32 ].

Synthesis of quantitative data

If there is sufficient clinical heterogeneity to expect that the underlying treatment effects differ between trials, or if we detect substantial statistical heterogeneity using the I 2 statistic, meta-analysis will not be appropriate, and a narrative synthesis of all quantitative study types will be undertaken. We will seek statistical advice for this part of the analysis if appropriate. Narrative synthesis will be based on guidance developed by Popay et al. [ 33 ] and as recommended by a Cochrane Review Group [ 34 ] and The Centre for Reviews and Dissemination (CRD) [ 22 ]. This will involve developing a preliminary synthesis, exploring relationships within and between the studies and assessing the robustness of the synthesis [ 33 ]. Assessment of the robustness of the synthesis will inform the assessment of confidence in the findings and will include the quality assessment scores of the individual studies, an assessment of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria [ 35 ] where these can be applied appropriately [ 36 ], and critical reflection on the synthesis process [ 22 , 34 ].

Synthesis of qualitative data

As the intention of the qualitative synthesis is interpretation and to generate new theoretical insights, meta-ethnography, as first described by Noblit and Hare [ 32 ], has been chosen as the most appropriate method to facilitate this [ 28 , 37 ]. This method is also appropriate when synthesising data from studies that have used different qualitative methodologies [ 37 ]. The synthesis will comprise the following steps based on meta-ethnography as proposed by Noblit and Hare [ 32 ]: reading the studies, identifying findings from one paper and comparing them to findings from another and generating a list of concepts. Next will follow the use of reciprocal translation, the identification of similarities in the concepts and developing themes and refutational translation which is the search for disconfirming or unexplained data, and finally, there will be synthesis of the themes into a “line of argument” synthesis, which is a summary statement of the findings and theoretical insights [ 32 ].

The confidence in the qualitative findings will be assessed using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) approach [ 38 ]. This includes four elements: methodological limitations of the individual studies, relevance to the review question, coherence and adequacy of the data. The overall CERQual assessment score ranging from high confidence to very low confidence of each finding will be made through discussion among all review authors [ 39 ]. The CERQual assessment of each synthesis finding will be provided as an appendix to the final review and will be summarised in a CERQual evidence summary table [ 40 ].

Several systematic reviews have applied meta-analysis to the data reported about outcomes associated with movement and positions adopted during labour and birth [ 2 , 3 ]. This has led to the publication of multiple national and international guidelines encouraging mobility and the use of comfortable positions of a woman’s choice during labour and birth [ 1 , 6 , 7 , 8 , 9 , 10 , 11 , 12 ]. National level data indicates ongoing restriction of women’s movement during labour and birth; however, there is a lack of evidence synthesis related to factors that contribute to this. This review will comprehensively and formally synthesise the available primary quantitative, qualitative and mixed-methods studies reporting data relating to this topic. The findings of this review will allow researchers, practitioners and policy makers to better understand the barriers and facilitators influencing women’s movement and the use of different positions during labour and birth. This will inform future research and the development of services designed to implement best-evidence concerning movement and positioning during labour and birth into clinical practice.

Abbreviations

African Journals Online

Applied Social Sciences Index and Abstracts

Confidence in the Evidence from Reviews of Qualitative Research

Cumulative Index to Nursing and Allied Health Literature

Centre for Reviews and Dissemination

Enhancing transparency in reporting the synthesis of qualitative research

International Federation of Gynecology and Obstetrics

Grading of Recommendations Assessment, Development and Evaluation

Medical Literature Analysis and Retrieval System Online

Medical subject headings

Mixed Methods Appraisal Tool

Population, Intervention, Control, Outcome

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

PRISMA for systematic review protocols

International prospective register of systematic reviews

United States of America

World Health Organization

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There is no financial support for this review. This review is being conducted as part of HW’s Masters in Clinical Research programme which is funded by the National Institute for Health Research. The views expressed are those of the authors and not necessarily of the NHS, the NIHR or the Department of Health.

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HW conceived the review, developed the search strategy and wrote the first draft of the protocol. AC contributed to the development of the search strategy and protocol and reviewed the initial and subsequent drafts. HW is the guarantor. Both authors read and approved the final manuscript.

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Additional files

Additional file 1:.

PRISMA-P checklist. Completed PRISMA-P checklist for this review protocol. (DOCX 23 kb)

Additional file 2:

MEDLINE search terms. Terms to be used when searching MEDLINE database. (DOCX 15 kb)

Additional file 3:

Data extraction form. Sample data extraction for use in the review. (DOCX 15 kb)

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Watson, H.L., Cooke, A. What influences women’s movement and the use of different positions during labour and birth: a systematic review protocol. Syst Rev 7 , 188 (2018). https://doi.org/10.1186/s13643-018-0857-8

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Effect of maternal birth positions on duration of second stage of labor: systematic review and meta-analysis

Marta berta.

1 Department of Reproductive and Women’s Health, School of Midwifery, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia

Helena Lindgren

2 Department of Women’s and Children’s Health, Karolinska Institute, Solna, Sweden

Kyllike Christensson

Sollomon mekonnen.

3 Institute of Public Health, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia

Mulat Adefris

4 Department of Gynecology and Obstetrics, School of Medicine, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia

Associated Data

The datasets supporting the conclusions of this article are included within the article.

It is believed that giving birth in an upright position is beneficial for both mother and the infant for several physiologic reasons. An upright positioning helps the uterus to contract more strongly and efficiently, the baby gets in a better position and thus can pass through the pelvis faster. Upright and lateral positions enables flexibility in the pelvis and facilitates the extension of the outlet. Before implementing a change in birthing positions in our clinics we need to review evidences available and context valid related to duration of second stage of labor and birthing positions. Therefore this review aimed to examine the effect of maternal flexible sacrum birth position on duration of second stage of labor.

The research searched articles using bibliographical Databases: Medline/PUBMED, SCOPUS, Google scholar and Google. All study designs were considered while investigating the impact of maternal flexible sacrum birthing positioning in relation duration of second stage of labor. Studies including laboring mothers with normal labor and delivery. A total of 1985 women were included in the reviewed studies. We included both qualitative and quantitative analysis.

We identified 1680 potential citations, of which 8 articles assessed the effect of maternal upright birth positioning on the reduction during the duration of second stage of labor. Two studies were excluded because of incomplete reports for meta analysis. The result suggested a reduction in duration of second stage of labor among women in a flexible sacrum birthing position, with a mean duration from 3.2–34.8. The pooled weighted mean difference with random effect model was 21.118(CI: 11.839–30.396) minutes, with the same significant heterogeneity between the studies (I 2  = 96.8%, p  < 000).

The second stage duration was reduced in cases of a flexible sacrum birthing position. Even though the reduction in duration varies across studies with considerable heterogeneity, laboring women should be encouraged to choose her comfortable birth position. Researchers who aim to compare different birthing positions should consider study designs which enable women to choose birthing position.

Prospero registration number

[ CRD42019120618 ]

The second stage of labor begins when the cervix is completely dilated (open) and ends with the birth of the baby. In research, the second stage is often divided into a passive phase, an active phase, and the actual birth of the baby when the baby actually emerges [ 1 ]. Giving birth in an upright position can benefit the mother and baby for several physiologic reasons [ 2 ]. When a laboring woman is in upright position to give birth, there is less risk of compressing the mother’s aorta, which means there is a better oxygen supply to the baby [ 3 ]. Upright positioning also helps the uterus contract more strongly and efficiently as a result it helps the baby get in a better position [ 2 , 4 ].

In summary, the purpose of implementation of an upright position is for the enhancement of uterine contractions, fetal condition, and the promotion of maternal comfort [ 5 – 7 ]. Flexible sacrum positions (FSP = knee-standing, on all fours, sitting on a birth seat and lateral) is where weight is taken off the sacrum, thereby allowing the pelvic outlet to expand well [ 8 , 9 ].

A Cochrane review examined duration of the second stage of labour, comparing limited birth positions (upright, birth-stool/squatting and birth chair/cushion) with supine/lithotomy positions, excluding water birth, mothers without epidural anesthesia and studies from low income countries. An update on this review was done in 2017 [ 10 , 11 ]. In our present study we take into account all studies incorporating the above mentioned birthing positions (FSP), from all settings, observational and experimental studies and year of publication. Even though the issue has frequently been studied; evidence related to alternative birthing positions is not well known. Among all clinical midwives, this knowledge helps midwives to encourage laboring women and their families to make informed decisions regarding positions to be used in childbirth [ 3 ]. In order for midwives to optimize their care for laboring women, there is a need for evidence to support and advocate for women during the labor and delivery process. Thus, systematic review and meta-analysis with the objective of assessing the effect of maternal flexible sacrum birthing positions on duration of the second stage of labor was conducted.

To determine the effect of maternal flexible sacrum birthing positions on duration of second stage of labor in comparison with supine position.

Eligibility criteria

Any cross sectional, observational, cohort studies and RCT studies comparing flexible sacrum (standing, kneeling, sitting, squatting and birthing ball and lateral positions) against supine position, were peer-reviewed and reported in original research articles were considered for the present review.

All pregnant women with normal labor at health facility, the main comparison was the use of any upright or lateral position during the second stage of labor (FSP) compared with supine or lithotomy/recumbent/semi-recumbent positions.

The primary outcome is duration of second stage of labor. No secondary outcome was taken in to consideration.

We excluded studies reported in languages other than English, systematic review and meta analysis, studies considering high risk pregnancy and inaccessible full-text articles.

Search strategy

Data base ( www.crd.york.ac.uk/prospero ) was explored to confirm whether systematic review or meta-analysis existed before. The titles of all appropriate abstracts and titles collected from electronic and manual searches were entered into the EndNote-7 reference software. The reference lists of all the articles were also scrutinized for further studies.

Potentially relevant articles for the review were identified by searching bibliographical Databases: Medline/PUBMED, JBI library and SCOPUS. Google scholar and Google were searched to include all pre-reviewed articles. Search terms used were directly related to the title: women, labor second stage, upright position, duration, supine position and birth. In the search strategy we included combination of keywords extracted from the title: effect Or influence AND maternal OR women AND positions (standing, kneeling, all four, sitting, squatting, lateral, supine) AND birth OR delivery OR parturition AND duration AND second stage of labor. Additional relevant articles were identified by searching the reference lists of full-text articles and grey literatures from Google and Google scholar.

Study selection

Each title and abstract was screened by two independent reviewers using a standardized form [ 12 ]. Each full text article was reviewed by two independent reviewers using standardized inclusion criteria: (a) presents primary data analysis; (b) uses a quantitative method of data collection and analysis (quantitative studies); (c) discusses maternal birth position in relation to duration of second stage; (d) discusses childbirth occurring in health facilities; and (e) was published in English. Discrepancies during title and abstract and full text screening were resolved by discussion with a third reviewer until consensus was reached.

Quality assessment

All papers selected for inclusion were subjected to a rigorous, independent appraisal by the investigators using standardized critical appraisal instruments adopted from JBI. The tool addresses both the external and internal validity and has multiple items for each type of study for risk of bias. Furthermore, it has nine items for cross-sectional and thirteen items for RCT to be used. The overall risk of study bias ranked into one of the four levels (High, Moderate, Low, Very Low), for inclusion or exclusion of studies. The reviewers for this study interpret this ranking system based on the recommendation from JBI reviewer manual, (High = 75–100%, Moderate = 50–75%, Low = 25–50 and < 25%). Hence we decided to include studies which score with high (75–100%) and moderate (50–75%). Accordingly, only one paper lies in the moderate range and the others seven lie in the high range [ 13 ].

To ascertain scientific rigor, we used the Preferred Reporting of Systematic Reviews and Meta-Analysis (PRISMA) guidelines for systematic data analysis [ 14 ]. The two reviewers were blinded to each other for screening of studies, data extraction, and risk of bias assessment parts of the review. If any differences seen when we compare results from the two reviewers, the third reviewer was communicated.

Data extraction and outcome of interest

Data were extracted from each study included in the review using a pre-constructed criteria based on the standardized JBI data extraction tool [ 15 ]. Two authors extract data and they compared the results; discrepancies were resolved by discussion by the reviewer made, for the decision third reviewer was contacted. We were contacted the original authors of the eligible studies through email or phone for further clarification of data. For each study we extracted the following domains.

  • i) Author(s) and years of publication
  • ii) Study designs (cross sectional, observational, cohort and RCT studies)
  • iii) Country or region
  • iv) Sample size for each groups
  • v) Main findings (mean and standard deviation of second stage duration in each group)

The outcome of interest was duration elapsed in the second stage of labor measured in minutes.

Data analysis

We undertook an initial descriptive analysis of the studies. Heterogeneity between estimates was assessed using the I 2 statistic, to describe the percentage of variation not because of sampling error across studies. An I 2 values above 75% indicates considerable heterogeneity [ 16 ].

Potential influences on mean estimates was investigated using subgroup analyses, we compared mean estimates by region, within studies. Pooled mean difference of labor duration of FSP birthing positions versus supine position in the second stage was analyzed using statistical meta-analysis software STATA version11.

The review process

Over all we found 1680 studies with our search strategies. The initial search from PUBMED yielded 1660 studies, another search from SCOPUS yielded 12 studies and from manual search we get 8 studies making a total of 1680, of which 10 duplicates were removed. After title and abstract screening 1645 studies were excluded since they didn’t fulfill the inclusion criteria, 25 potentially relevant articles were searched for full text. Eight studies met the inclusion criteria and 17 studies were excluded. Of these 3 studies were duplicates, one study was a systematic review, 9studies were not related to birthing position and 4 were not pertaining to duration of second stage of labor. Finally, we synthesize 8 studies for systematic review and 6 studies for meta analysis (Fig.  1 ).

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PRISMA Flow chart of search and study inclusion process

Characteristics of included studies

The sample size from the 8 included studies with the total of 1985 laboring women (933 for supine position and 938 for flexible sacral position). As seen from Table  1 , one of the studies was a cross-sectional study, 7 studies were RCT. One study was conducted in an African country, and three were done in India. The other four were done in high-income countries (Spain, Turkey, Finland and U.K).

Presentation of the summary results of the included studies

Author, year and countryStudy designTotal sample sizePositions in comparisonResultsBias/ Limitation
Mean (minutes) for Upright/lateralMean (minutes) for SupineLength of time shortened by upright position
Simaro M., 2017 (Spain)RCT155All upright/lateral Vs supine94.6124.329.7Low risk
Denakpo J., 2012 (Benrin)CS980Standing, sitting and squatting Vs supine159.5179.319.8Low risk
Gupta JK, 1989 (U.K)RCT114Squatting Vs supine36404Low risk
Mathew A., 2012(India)RCT60Birthing ball & ambulation Vs supine23.949.825.9Low risk
Mraloglu O., 2017 (Turky)RCT100Squatting Vs supine21.0255.434.38Low risk
Dabral A., 2018 (India)RCT300Kneeling Vs supine23.939.3815.48Low risk
Marittila M., 1983 (Finland)RCT100Sitting Vs supinr21.8253.2Low risk
Thilagavathy G.,2012 India)RCT200Half sitting Vs supine566711Low risk

The difference in duration of second stage of labor from supine to FSP was high across the studies that reported all in minutes, ranging from 3.2 to 34.4 min. All the included studies were conducted in health facilities. Among the 8 included studies, two studies compare squatting position Vs supine [ 16 , 17 ], two studies compare sitting position Vs supine, [ 18 , 19 ], one compare keeling Vs supine [ 20 ], two studies compare flexible sacral position Vs supine [ 21 , 22 ] and one study compare ambulation and birthing ball with supine position. Two studies allowed laboring women for free choice of birthing position [ 21 , 22 ]. Two studies calculate minimum sample size using sample size calculation with the assumptions for double population [ 16 , 22 ].

Weighted mean difference of duration of second stage of labor

In our meta analysis two studies were excluded [ 16 , 19 ] for their incomplete report. The overall estimated mean difference of duration of second stage of labor from the included six studies with fixed effect model showed a significant heterogeneity between the studies. So that the main meta analysis was fitted to random effect model to get the pooled mean. The duration of second stage of labor across the studies included was ranges between 3.2–34.38 min. The pooled weighted mean difference with fixed effect model was 23.47 (95%CI: 21.96–24.97) minutes and with random effect model was 21.118(CI: 11.839–30.396) minutes, with the same significant heterogeneity between the studies (I 2  = 96.8%; very low-quality evidence, p  < 000) (Fig.  2 ).

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Duration of second stage with random effect model

Subgroup analysis

Subgroup analysis was done based on region in order to identify the potential heterogeneity between studies. In this sub-group analysis studies were grouped in to low-middle and high income regions to see the effect on heterogeneity. The sub-total weighted mean difference of duration of second stage of labor was higher in high income region across studies as compared to low-middle income region. Hence studies conducted in low-middle income regions showed significant improvement in heterogeneity (18.87, 95% CI: 14.55–23.18, I 2: 68.7%, P  < 0.041), as compared to the developed region (22.32, 95% CI: − 0.48-45.13, I 2 : 97.9%, P  < 0.000) as shown in Fig.  3 .

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Sub-group analysis by region

Sensitivity analysis

The effect of an individual study for causing the heterogeneity was conducted, but no any influential study was identified since all studies were within the confidence interval. Thus, no further analysis for sensitivity was needed (Fig.  4 ).

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Assessment of publication bias

Publication bias was assessed using Egger’s test. The estimated bias coefficient was − 2.14 (Egger bias B = − 2.14 (95% CI: − 7.03-2.75)) with a standard error of 1.76, giving a p -value of 0.291. Thus, the test provides no evidence for the presence of small-study effect. Figure ​ Figure5 5 presents the funnel plot result with the 95% confidence limit.

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Presentation of funnel plot

The review showed that using a flexible sacrum position can reduce the duration of the second stage of labor by 21.12 min. The reduction was contributed mainly by a large reduction in the three studies of the birthing ball, flexible sacrum and squatting positions reduce 25.9, 29.7 and 34.38 min respectively [ 17 , 22 , 23 ]. The reduction in duration is in line with other review and meta-analysis conducted both in UK in different times, in contrast other meta-analysis done in Australia and UK, didn’t show any reduction in duration of second stage [ 10 , 11 ]. This difference may be due to the variable trial quality, inconsistencies within trials (in different birth position) used in different period of time and in different settings and heterogeneity of participants in individual studies. The reduction in second stage duration have greater advantages for both the mother and her infant by decreasing unnecessary intervention for the mother and reduced fetal heart rate abnormality, neonatal hypoxia and acidosis [ 24 ] . In another way reduction in second stage of labor may cause both maternal and neonatal trauma due to fast expulsion of the fetal head [ 25 ].

The sub-group meta-analysis reported that an overall pooled mean difference in reduction of second stage of labor among the low-middle income regions was significant as compared to high-income region. Keeping the heterogeneity between the studies for the high-income region is highly considerable, thus it ends up with wide confidence interval and include non-significant value.

The reduction in duration of second stage of labor between two studies with same comparison (squatting Vs supine) showed high difference, ranges between 4 and 34.38 min [ 16 , 17 ].

In the present review, we only found two studies where women in the intervention group could choose freely between the upright or lateral positions. One of the studies compared flexible sacrum position Vs supine, which resulted in a mean difference of 29.7 min [ 22 ]. Women used a minimum of two and a maximum 5types of flexible sacrum positions until they completed the labor and delivery [ 22 ]. The other study compared three upright positions (sitting, standing and squatting) Vs supine, this also results in remarkable reduction in duration (19.8 min) [ 21 ], but it didn’t compare the difference in reduction of duration of second stage of labor of each upright against supine. In these two studies women were allowed to freely choose between the upright or lateral positions. Having this opportunity to choose, might make women become relaxed and feel comfortable. It also might facilitate the rotation and descent of the baby’s head and hence contribute to the reduction in duration of second stage of labor [ 26 ].

Limitation of this review

Our review uses limited data bases (PUBMED & SCOPUS) even though extensive search was done using these two data bases. We couldn’t however access other data bases because their sites are not accessible. There was a high variation in sample size, setting, and time between studies that may affect the quality of our review.

Flexible sacrum birthing position has effect on reduction in duration of the second stage of labor with a considerable variation was reported. This reduction in duration of second stage of labor should be discussed among health care providers who care for women during labor and childbirth.

Implications

Laboring women should be encouraged to choose a birth positions that she finds comfortable. Researchers who aim to compare different birth positions should consider study designs which enables women to choose birthing position.

Acknowledgments

I would like to express my deepest heartfelt thanks to Dr. Helena Lindgren (PHD, Professor), Dr. Kylliky Christensson (PHD, Professor), Dr. Sollomon Mekonnen(PHD, Asso. Professor), and Dr Mulat Adefris(Masters, Asso. Professor) for their generous advice and unreserved comment on the study of this systematic review and meta-analysis, School Midwifery and institute of Public Health which started me on this path and made it possible for me to continue and the University of Gondar, College of Medicine and Health Sciences, are sincerely acknowledged. Very special thanks go to Dessie Abebaw for his invaluable help and encouragement.

Abbreviations

FSPFlexible Sacrum Position
JBIJoanna Briggs Institute
PRISMAPreferred Reporting of Systematic Reviews and Meta-Analysis
RCTRandomized Controlled Trial
U.KUnited Kingdom

Authors’ contributions

All authors have their own contribution: MB: worked on searching the studies, screening, data extraction and writing up of the manuscript, SM: participated in screening, data extraction and writing up of the manuscript. HL: participated in writing up of the manuscript. KC: participated in writing up of the manuscript, MA: participated in writing up of the manuscript. All authors read and approved the final manuscript.

Availability of data and materials

Ethics approval and consent to participate.

Not applicable.

Consent for publication

Competing interests.

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Marta Berta, Email: moc.liamg@7atrebm .

Helena Lindgren, Email: [email protected] .

Kyllike Christensson, Email: [email protected] .

Sollomon Mekonnen, Email: moc.oohay@nennokemolos .

Mulat Adefris, Email: moc.liamg@wsirfedatalum .

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