Lithotomy vs. Other Positions in Second Stage Labour With ...€¦ · labour and results in more instrumental deliveries. It has been suggested that a more upright position of the - [PDF Document] (2024)

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Date: 02 Jun 2017 Sourced Searched: Medline. Embase, Cinahl,PubMed.

Lithotomy vs. Other Positions in Second Stage Labour WithEpidural

Evidence Summary:

Based on a recently updated Cochrane review (Feb 2017) there isinconclusive evidence to favour the use of either the lithotomy(recumbent) or upright positioning during second stage labour forwomen with epidural analgesia. Based on primary outcomes (operativedelivery, duration of second stage labour and trauma to the birthcanal) there is no clear difference between upright and recumbentpositions. There are also no differences in terms of newbornoutcomes; abnormal foetal heart patterns, abnormal cord PH andadmission to neonatal intensive care.

More studies with larger sample sizes are needed in order forsolid conclusions to be made about the effect of position on labourin women with an epidural. Two studies are currently ongoing theresults of which will be incorporated into an updated Cochranereview. Women with an epidural should be encouraged to use whateverposition they find comfortable in the second stage of labour.

Source: Kibuka M, Thornton JG. Position in the second stage oflabour for women with epidural anaesthesia. Cochrane Database ofSystematic Reviews 2017, Issue 2. Art. No.: CD008070. DOI:10.1002/14651858.CD008070.pub3.

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008070.pub3/pdfhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008070.pub3/pdfhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008070.pub3/pdfhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008070.pub3/pdf

1. Position in the second stage of labour for women withepidural anaesthesia.

Author(s): Kibuka, Marion; Thornton, Jim G

Source: The Cochrane database of systematic reviews; Feb 2017;vol. 2 ; p. CD008070

Publication Date: Feb 2017

Publication Type(s): Research Support, Non-u.s. Gov't JournalArticle Review

Available in full text at Cochrane Library, The - from JohnWiley and Sons

Abstract: BACKGROUND Epidural analgesia for pain relief inlabour prolongs the second stage of labour and results in moreinstrumental deliveries. It has been suggested that a more uprightposition of the mother during all or part of the second stage maycounteract these adverse effects. This is an update of a Cochranereview first published in 2013.OBJECTIVESTo assess the effects ofdifferent birthing positions (upright and recumbent) during thesecond stage of labour, on important maternal and fetal outcomesfor women with epidural analgesia.SEARCH METHODSWe searchedCochrane Pregnancy and Childbirth's Trials Register (19 September2016) and reference lists of retrieved studies.SELECTIONCRITERIAAll randomised or quasi-randomised trials includingpregnant women (either primigravidae or multigravidae) in thesecond stage of induced or spontaneous labour receiving epiduralanalgesia of any kind. Cluster-RCTs would have been eligible forinclusion in this review but none were identified. Studiespublished in abstract form only were eligible for inclusion.Weassumed the experimental type of intervention to be the maternaluse of any upright position during the second stage of labour,compared with the control intervention of the use of any recumbentposition.DATA COLLECTION AND ANALYSISTwo review authorsindependently assessed trials for inclusion, assessed risk of bias,and extracted data. Data were checked for accuracy. We contactedstudy authors to try to obtain missing data.MAIN RESULTSFiverandomised controlled trials, involving 879 women, comparingupright positions versus recumbent positions were included in thisupdated review. Four trials were conducted in the UK and one inFrance. Three of the five trials were funded by the hospitaldepartments in which the trials were carried out. For the otherthree trials, funding sources were either unclear (one trial) ornot reported (two trials). Each trial varied in levels of bias. Weassessed all the trials as being at low or unclear risk ofselection bias. None of the trials blinded women, staff or outcomeassessors. One trial was poor quality, being at high risk ofattrition and reporting bias. We assessed the evidence using theGRADE approach; the evidence for most outcomes was assessed asbeing very low quality, and evidence for one outcome was judged asmoderate quality.Overall, we identified no clear difference betweenupright and recumbent positions on our primary outcomes ofoperative birth (caesarean or instrumental vagin*l) (average riskratio (RR) 0.97; 95% confidence interval (CI) 0.76 to 1.29; fivetrials, 874 women; I² = 54% moderate-quality evidence), or durationof the second stage of labour measured as therandomisation-to-birth interval (average mean difference -22.98minutes; 95% CI -99.09 to 53.13; two trials, 322 women; I² = 92%;very low-quality evidence). Nor did we identify any cleardifferences in any other important maternal or fetal outcome,including trauma to the birth canal requiring suturing (average RR0.95; 95% CI 0.66 to 1.37; two trials; 173 women; studies = two; I²= 74%; very low-quality evidence), abnormal fetal heart patternsrequiring 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% CI0.18 to 2.10; one trial; 66 infants; very low-quality evidence) oradmission to neonatal intensive care unit (RR 0.54; 95% CI 0.02 to12.73; one trial; 66 infants; very low-quality evidence). However,the CIs around each estimate were wide, and clinically importanteffects have not been ruled out. Outcomes were downgraded for studydesign, high heterogeneity and imprecision in effectestimates.There were no data reported on blood loss (greater than500 mL), prolonged second stage or maternal experience andsatisfaction with labour. Similarly, there were no analysable dataon Apgar scores, and no data reported on the need for ventilationor for perinatal death.AUTHORS' CONCLUSIONSThere are insufficientdata to say anything conclusive about the effect of position forthe second stage of labour for women with epidural analgesia. TheGRADE quality assessment of the evidence in this review rangedbetween moderate to low quality, with downgrading decisions basedon design

http://linker2.worldcat.org/?rft.institution_id=129803&spage=CD008070&pkgName=Cochrane&issn=1469-493X&linkclass=to_article&jKey=10.1002%2F14651858&provider=wiley&date=2017-02&aulast=Kibuka%2C+Marion%3B+Thornton%2C+Jim+G&atitle=Position+in+the+second+stage+of+labour+for+women+with+epidural+anaesthesia.&title=Cochrane+Library%2C+The&rft.content=fulltext%2Cprint&eissn=1465-1858&linkScheme=wiley.cochrane&jHome=http%3A%2F%2Fonlinelibrary.wiley.com%2Fbook%2F10.1002%2F14651858&volume=2&rft.id=info%3Apmid%2F&rft.order_by=preference&linktype=best

limitations in the studies, inconsistency, and imprecision ofeffect estimates.Women with an epidural should be encouraged to usewhatever position they find comfortable in the second stage oflabour.More studies with larger sample sizes will need to beconducted in order for solid conclusions to be made about theeffect of position on labour in women with an epidural. Two studiesare ongoing and we will incorporate the results into this review ata future update.Future studies should have the protocol registered,so that sample size, primary outcome, analysis plan, etc. are allclearly prespecified. The time or randomisation should be recorded,since this is the only unbiased starting time point from which theeffect of position on duration of labour can be estimated. Futurestudies might wish to include an arm in which women were allowed tochoose the position in which they felt most comfortable. Futurestudies should ensure that both compared positions are acceptableto women, that women can remain in them for most of the late partof labour, and report the number of women who spend time in theallocated position and the amount of time they spend in this orother positions.

Database: Medline

2. Maternal positions and mobility during first stagelabour.

Author(s): Lawrence, Annemarie; Lewis, Lucy; Hofmeyr, G Justus;Styles, Cathy

Source: The Cochrane database of systematic reviews; Oct 2013(no. 10); p. CD003934

Publication Date: Oct 2013

Publication Type(s): Research Support, Non-u.s. Gov'tMeta-analysis Comparative Study Journal Article Review

Available in full text at Cochrane Library, The - from JohnWiley and Sons

Abstract:BACKGROUNDIt is more common for women in both high- andlow-income countries giving birth in health facilities, to labourin bed. There is no evidence that this is associated with anyadvantage for women or babies, although it may be more convenientfor staff. Observational studies have suggested that if women lieon their backs during labour this may have adverse effects onuterine contractions and impede progress in labour, and in somewomen reduce placental blood flow.OBJECTIVESTo assess the effectsof encouraging women to assume different upright positions(including walking, sitting, standing and kneeling) versusrecumbent positions (supine, semi-recumbent and lateral) for womenin the first stage of labour on duration of labour, type of birthand other important outcomes for mothers and babies.SEARCHMETHODSWe searched the Cochrane Pregnancy and Childbirth Group'sTrials Register (31 January 2013).SELECTION CRITERIARandomised andquasi-randomised trials comparing women randomised to uprightversus recumbent positions in the first stage of labour.DATACOLLECTION AND ANALYSISW e used methods described in the CochraneHandbook for Systematic Reviews of Interventions for carrying outdata collection, assessing study quality and analysing results. Tworeview authors independently evaluated methodological quality andextracted data for each study. We sought additional informationfrom trial authors as required. We used random-effects analysis forcomparisons in which high heterogeneity was present. We reportedresults using the average risk ratio (RR) for categorical data andmean difference (MD) for continuous data.MAIN RESULTSResults shouldbe interpreted with caution as the methodological quality of the 25included trials (5218 women) was variable.For Comparison 1: Uprightand ambulant positions versus recumbent positions and bed care, thefirst stage of labour was approximately one hour and 22 minutesshorter for women randomised to upright as opposed to recumbentpositions (average MD -1.36, 95% confidence interval (CI) -2.22 to-0.51; 15 studies, 2503 women; random-effects, T(2) = 2.39, Chi(2)= 203.55, df = 14, (P < 0.00001), I(2) = 93%). Women who wereupright were also less likely to have caesarean section (RR 0.71,95% CI 0.54 to 0.94; 14 studies, 2682 women) and less likely tohave an epidural (RR 0.81, 95% CI 0.66 to 0.99, nine studies, 2107women; random-effects, T(2) = 0.02, I(2) = 61%). Babies of motherswho

http://linker2.worldcat.org/?rft.institution_id=129803&spage=CD003934&pkgName=Cochrane&issn=1469-493X&linkclass=to_article&jKey=10.1002%2F14651858&issue=10&provider=wiley&date=2013-10&aulast=Lawrence%2C+Annemarie%3B+Lewis%2C+Lucy%3B+Hofmeyr%2C+G+Justus%3B+Styles%2C+Cathy&atitle=Maternal+positions+and+mobility+during+first+stage+labour.&title=Cochrane+Library%2C+The&rft.content=fulltext%2Cprint&eissn=1465-1858&linkScheme=wiley.cochrane&jHome=http%3A%2F%2Fonlinelibrary.wiley.com%2Fbook%2F10.1002%2F14651858&rft.id=info%3Apmid%2F&rft.order_by=preference&linktype=best

were upright were less likely to be admitted to the neonatalintensive care unit, however this was based on one trial (RR 0.20,95% CI 0.04 to 0.89, one study, 200 women). There were nosignificant differences between groups for other outcomes includingduration of the second stage of labour, or other outcomes relatedto the well being of mothers and babies.For Comparison 2: Uprightand ambulant positions versus recumbent positions and bed care(with epidural: all women), there were no significant differencesbetween groups for outcomes including duration of the second stageof labour, or other outcomes related to the well being of mothersand babies.AUTHORS' CONCLUSIONS There is clear and importantevidence that walking and upright positions in the first stage oflabour reduces the duration of labour, the risk of caesarean birth,the need for epidural, and does not seem to be associated withincreased intervention or negative effects on mothers' and babies'well being. Given the great heterogeneity and high performance biasof study situations, better quality trials are still required toconfirm with any confidence the true risks and benefits of uprightand mobile positions compared with recumbent positions for allwomen. Based on the current findings, we recommend that women inlow-risk labour should be informed of the benefits of uprightpositions, and encouraged and assisted to assume whatever positionsthey choose.

Database: Medline

3. Alternative model of birth to reduce the risk of assistedvagin*l delivery and perineal trauma.

Author(s): Walker C; Rodríguez T; Herranz A; Espinosa JA;Sánchez E; Espuña-Pons M

Source: International urogynecology journal; Sep 2012; vol. 23(no. 9); p. 1249-1256

Publication Date: Sep 2012

Publication Type(s): Journal Article; Randomized ControlledTrial; Research Support, Non-U.S. Gov't

PubMedID: 22297706

Available in full text at International Urogynecology Journal -from Springer Link Journals

Available in full text at International Urogynecology Journal -from ProQuest

Abstract:INTRODUCTION AND HYPOTHESIS: This study was conductedto evaluate the effects of an alternative model of birth (AMB) onthe incidence of assisted vagin*l delivery (AVD) and perinealtrauma (PT).METHODS: One hundred ninety-nine women with epiduralanesthesia were randomized to a traditional model of birth (TMB) (n= 96) or AMB (n = 103). Women in TMB pushed immediately aftercomplete dilatation and delivered in lithotomy position. In AMB,women followed a postural changes protocol while they delayedpushing and used a specific lateral position for delivery.RESULTS:AMB was associated with a significant reduction in AVD comparedwith TMB (19.8% vs 42.1%, p CONCLUSION: A combination of posturalchanges during the passive expulsive phase of labor and lateralposition during active pushing time is associated with reductionsin AVD and PT.

Database: PubMed

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4. Safe maternal positioning during labor and delivery

Author(s): Pridjian G.

Source: Obstetrics and Gynecology; Aug 2011; vol. 118 (no. 2);p. 413-414

Publication Date: Aug 2011

Publication Type(s): Editorial

Available in print at Patricia Bowen Library and KnowledgeService West Middlesex university Hospital - from Obstetrics andGynecology

Available in full text at Obstetrics and Gynecology - fromOvid

Database: EMBASE

5. Effects of postural changes during the second stage of laboramong women with epidural analgesia

Author(s): Simarro M.; Salinas C.; Martinez A.; Henriquez A.;Garcia G.; Espinosa J.; Walker C.

Source: International Urogynecology Journal and Pelvic FloorDysfunction; Jun 2011; vol. 22

Publication Date: Jun 2011

Publication Type(s): Conference Abstract

Available in full text at International Urogynecology Journal -from Springer Link Journals

Available in full text at International Urogynecology Journal -from ProQuest

Abstract:Objective: To evaluate the effectiveness of a protocolof postural changes during the second stage of labor among womenwith epidural analgesia on mode of delivery, perineal trauma andthe incidence of urinary incontinence postpartum. Background: Theintroduction of epidural analgesia has led to significant progressin reducing the pain of labor. However, a disadvantage is that itinterferes with the normal mechanism of labor and extends theexpulsive phase. The inhibition of the pushing efforts and thereduced possibility of adopting alternative position during thesecond stage of labor could be related with the increased ofinstrumental delivery in women with epidural analgesia. Recentstudies have shown that maternal movement and position changesduring labor with epidural analgesia could reduce instrumentaldeliveries (1), decrease pain, produce good maternal-fetalcirculation, decrease length of labor and decrease perineal trauma(2). Methods: We randomly assigned 150 women at full dilation toeither and experimental group (EG) (n=73) or control group (n=77).Both groups delayed pushing and used lithotomy position duringdelivery. Women in the EG were encourage to follow a protocol ofpostural change between different positions (hands and knees,sitting, lateral, kneeling and supine) which was monitorized by aphysiotherapist to assure the neutral position of the lumbo-pelvicspine in all positions. Women in the CG rest in horizontal positionwithout perform postural changes. Statistical analyses wereperformed using Pearson chi-square for categorical and Student ttest for continuous variables. Logistic regression models were usedto evaluate whether obstetrical factors/interventions wereindependently associated with assisted vagin*l delivery, as well aswith perineal trauma. P values 0.05 lower than were consideredstatistically significant. Results: Instrumental delivery rate wassignificantly reduced in EG (39% vs 24% in CG and EG, p=0,005) aswell as cesarean sections (10.4% vs 1.4%, CG and EG, p=0.05), Table1. EG was associated with a significant redution in the incidenceof episiotomy (31.2% vs 17.8%, CG and EG, p

fetal head station in the EG at the start of the activeexpulsive phase was at lower level of the birth canal that thefetal head of the CG. (Table presented) Conclusions: Promotepostural changes during the expulsive phase of labor in women withepidural analgesia is associated with a lower incidence ofinstrumental delivery, cesarean section and length of second stageof labor. In addition, the protocol present in this trial isassociated with a lower rate of episiotomy and sphinterlacerations.

Database: EMBASE

6. A meta-analysis of upright positions in the second stage toreduce instrumental deliveries in women with epiduralanalgesia.

Author(s): Roberts CL; Algert CS; Cameron CA; Torvaldsen S

Source: Acta obstetricia et gynecologica Scandinavica; Aug 2005;vol. 84 (no. 8); p. 794-798

Publication Date: Aug 2005

Publication Type(s): Comparative Study; Journal Article;Meta-Analysis; Research Support, Non-U.S. Gov't; Review

PubMedID: 16026407

Available in full text at Acta Obstetricia et GynecologicaScandinavica - from John Wiley and Sons

Abstract:BACKGROUND: Epidural analgesia is associated with anincreased risk of instrumental delivery. We, in this study, presenta systematic review in order to assess the effectiveness ofmaintaining an upright position during the second stage of labor toreduce instrumental deliveries among women choosing epiduralanalgesia. The study population included women with uncomplicatedpregnancies at term with epidural analgesia established in thefirst stage of labor.METHODS: We searched MEDLINE, EMBASE, andCINAHL databases and the Cochrane Trials Register up to July 2003and cross-checked the reference lists of published studies. Trialeligibility and outcomes were pre-specified. Group tabular datawere obtained for each trial and were analyzed by usingmeta-analytic techniques.RESULTS: Only two studies were includedwith data on 281 women (166 upright and 115 recumbent). Uprightpositions in the second stage were associated with anon-significant reduction in the risk of both instrumental delivery(relative risk (RR) = 0.77, 95% confidence interval (CI) =0.46-1.28) and cesarean section (RR = 0.57, 95% CI = 0.28-1.16).Both studies reported a statistically significant reduction inlabor duration associated with upright positions. Data on otheroutcomes, including perineal trauma, postpartum hemorrhage,maternal satisfaction, and infant well-being, wereinsufficient.CONCLUSIONS: There were insufficient data to show asignificant benefit from upright positions in the second stage oflabor for women who choose epidural or to evaluate safety aspects.However the magnitude of the reductions in instrumental deliveryand cesarean section warrants an adequately powered randomized,controlled trial to fully evaluate the practice of uprightpositions in the second stage for women with an epidural.

Database: PubMed

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7. A prospective randomised trial on the effect of position inthe passive second stage of labour on birth outcome in nulliparouswomen using epidural analgesia.

Author(s): Downe S; Gerrett D; Renfrew MJ

Source: Midwifery; Jun 2004; vol. 20 (no. 2); p. 157-168

Publication Date: Jun 2004

Publication Type(s): Academic Journal

Available in print at Patricia Bowen Library and KnowledgeService West Middlesex university Hospital - from Midwifery

Abstract:OBJECTIVE: To determine whether the rate ofinstrumental birth in nulliparous women using epidural analgesia isaffected by maternal position in the passive second stage oflabour. DESIGN: A pragmatic prospective randomised trial. SETTING:Consultant maternity unit in the Midlands. PARTICIPANTS: Onehundred and seven nulliparous women using epidural analgesia andreaching the second stage of labour with no contraindications tospontaneous birth. INTERVENTIONS: The lateral versus the supportedsitting position during the passive second stage of labour.MEASUREMENTS: Mode of birth, incidence of episiotomy, and perinealsuturing. FINDINGS: Recruitment was lower than anticipated (107 vs.220 planned). Lateral position was associated with lower rates ofinstrumental 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 instrumentalbirth in the sitting group was 2.2 (CI 1.00-4.6). Logisticregression of potential confounder variables was undertaken, due toa large variation in maternal weight between the randomised groups.Of the nine possible confounders tested, only position of thebaby's head at full dilation affected the risk of instrumentalbirth significantly (p=0.4, OR 2.7 where the fetal head was in thelateral or posterior position). Maternal weight did not appear tohave any effect. The odds ratio for instrumental delivery for womenrandomised to the sitting position was slightly higher within thelogistic regression model (adjusted OR 2.3). KEY CONCLUSIONS: Womenrandomised to the lateral position had a better chance of aspontaneous vagin*l birth than those randomised to the supportedsitting position. Position of the babies head at full dilation hadan additional effect on mode of birth. These effects are notconclusively generalizable. RECOMMENDATIONS FOR PRACTICE: Thelateral position is likely to be at best beneficial, and at theworst no less harmful than the sitting position for most women andtheir babies who meet the criteria set for this study. Conclusiveevidence for or against the technique should be established usinglarger trials.

Database: CINAHL

http://linker2.worldcat.org/?jHome=http%3A%2F%2Fwww.hlisd.org%2FLibraryDetail.aspx%3Flibraryid%3D3667&linktype=besthttp://linker2.worldcat.org/?jHome=http%3A%2F%2Fwww.hlisd.org%2FLibraryDetail.aspx%3Flibraryid%3D3667&linktype=best

8. Use of upright positioning with epidural analgesia: findingsfrom an observational study.

Author(s): Mayberry LJ; Strange LB; Suplee PD; Gennaro S

Source: MCN. The American journal of maternal child nursing;2003; vol. 28 (no. 3); p. 152-159

Publication Date: 2003

Publication Type(s): Journal Article

PubMedID: 12771693

Available in full text at MCN, American Journal of MaternalChild Nursing - from Ovid

Abstract: PURPOSE: To present research findings and relatednursing implications from an observational study designed toevaluate the use of upright positioning during second stage laborwith patients who had received low-dose epidural analgesia.STUDYDESIGN AND METHODS: This descriptive study evaluated outcomes froma sample of 74 healthy women having their first childbirth. Theyhad all received epidural analgesia during the first and secondstages of labor. Data were also collected by nurses on the use ofbirthing beds, and the extent of physical and emotional support thewomen needed while following the upright positioning studyprotocol.RESULTS: All women were able to maintain upright positionsthroughout the second stage of labor following epidural analgesiaadministration. No adverse neonatal outcomes or maternal problems(such as excessive vagin*l bleeding) were documented.CLINICALIMPLICATIONS: Although women were capable of assuming uprightpositions during second stage, the study results indicated thatconstant physical and emotional support was necessary for mostwomen. Future research on methods to prepare women for multipleposition options after administration of low-dose epiduralanalgesia should be undertaken. In addition, nurses should evaluatethe benefits of upright positioning in terms of facilitatingprogress of labor.

Database: PubMed

9. Maternal positioning in labor with epidural analgesia.Results from a multi-site survey.

Author(s): Gilder, Kathy; Mayberry, Linda J; Gennaro, Susan;Clemmens, Donna

Source: AWHONN lifelines; 2002; vol. 6 (no. 1); p. 40-45

Publication Date: 2002

Publication Type(s): Research Support, Non-u.s. Gov'tMulticenter Study Journal Article

Available in full text at AWHONN Lifelines - from John Wiley andSons

Database: Medline

http://linker2.worldcat.org/?rft.institution_id=129803&spage=152&pkgName=lwwtotalaccess2015q1wneurology&ovid.baseurl=http%3A%2F%2Fovidsp.ovid.com%2Fathens%2F&issn=0361-929X&linkclass=to_article&jKey=00005721-000000000-00000&issue=3&provider=Ovid&date=2003&aulast=Mayberry+LJ%3B+Strange+LB%3B+Suplee+PD%3B+Gennaro+S&atitle=Use+of+upright+positioning+with+epidural+analgesia%3A+findings+from+an+observational+study.&title=MCN%2C+American+Journal+of+Maternal+Child+Nursing&rft.content=fulltext%2Cprint&linkScheme=ovid&jHome=http%3A%2F%2Fovidsp.ovid.com%2Fathens%2Fovidweb.cgi%3FT%3DJS%26NEWS%3Dn%26CSC%3DY%26PAGE%3Dtoc%26D%3Dovft%26AN%3D00005721-000000000-00000%26ID%3D%26PASSWORD%3D&volume=28&dbKey=OVFT&rft.id=info%3Apmid%2F12771693&rft.order_by=preference&linktype=besthttp://linker2.worldcat.org/?rft.institution_id=129803&spage=40&pkgName=fullcollection2013nhs&issn=1091-5923&linkclass=to_article&jKey=10.1111%2F%28ISSN%291552-6356&issue=1&provider=wiley&date=2002&aulast=Gilder%2C+Kathy%3B+Mayberry%2C+Linda+J%3B+Gennaro%2C+Susan%3B+Clemmens%2C+Donna&atitle=Maternal+positioning+in+labor+with+epidural+analgesia.+Results+from+a+multi-site+survey.&title=AWHONN+Lifelines&rft.content=fulltext%2Cprint&eissn=1552-6356&linkScheme=wileyathens&jHome=http%3A%2F%2Fonlinelibrary.wiley.com%2Fshibboleth%2Fwayfless%3Feid%3Dhttps%3A%2F%2Fidp.eng.nhs.uk%2Fopenathens%26page%3Dhttp%3A%2F%2Fonlinelibrary.wiley.com%2Fjournal%2F10.1111%2F%28ISSN%291552-6356&volume=6&rft.id=info%3Apmid%2F&rft.order_by=preference&linktype=best

10. Upright versus recumbent position in the second stage oflabour in women with combined spinal-epidural analgesia.

Author(s): Golara, M; Plaat, F; Shennan, A H

Source: International journal of obstetric anesthesia; Jan 2002;vol. 11 (no. 1); p. 19-22

Publication Date: Jan 2002

Publication Type(s): Randomized Controlled Trial Clinical TrialJournal Article

Abstract:Neuraxial blockade is widely used for pain relief inlabour. This form of analgesia may be associated with an increasein instrumental delivery rates due to dystocia. 'Traditional'epidurals cause motor blockade and hence immobility. Using a lowdose anaesthetic-opioid combination with either epidural orcombined spinal-epidural, selective sensory blockade can beachieved, allowing mobility as well as pain relief. In this study,we randomised women with combined spinal-epidural analgesia eitherto mobilise (upright group n = 25) or to remain recumbent (n = 41)in the second stage of labour. We found women in the upright grouphad 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 theupright group, this was not statistically significant. Women whowere randomised to the upright group, did actually mobilise. Weconclude that mobilisation in the second stage of labour ispossible, and may reduce the length of the second stage.

Database: Medline

11. The effect of maternal position on fetal heart rate duringepidural or intrathecal labor analgesia.

Author(s): Eberle, R L; Norris, M C; Eberle, A M; Naulty, J S;Arkoosh, V A

Source: American journal of obstetrics and gynecology; Jul 1998;vol. 179 (no. 1); p. 150-155

Publication Date: Jul 1998

Publication Type(s): Research Support, Non-u.s. Gov't RandomizedControlled Trial Clinical Trial Journal Article

Abstract:OBJECTIVEThis study was designed to determine therelationship between maternal position and the incidence ofprolonged decelerations after epidural bupivacaine or intrathecalsufentanil analgesia for labor.STUDY DESIGNLaboring, healthy, termparturient women, with reassuring fetal heart rate tracings,requesting either epidural (n = 145) or intrathecal (n = 160)analgesia were randomly assigned to lie either supine with measured30-degree left uterine displacement (n = 136) or in the leftlateral decubitus position (n = 145). Patients received eitherintrathecal sufentanil, 10 microg, or epidural 0.25% bupivacaine,13 mL. An obstetrician, unaware of patient position or type ofanesthesia, examined the fetal heart rate tracings.RESULTSNodemographic differences were noted among the groups. Prolongeddecelerations occurred with equal frequency after epiduralbupivacaine and intrathecal sufentanil (3.9%). Prolongeddecelerations were not related to maternal position. No emergencycesarean deliveries were performed as a result of prolongeddecelerations. Prolonged decelerations correlated with thefrequency of contractions before induction of analgesia (P <.05). Fewer fetal heart rate accelerations were noted afterintrathecal sufentanil than after epidural bupivacaine (P <.005). More ephedrine was used after epidural bupivacaine (P <.001). Patients who received epidural analgesia in the left lateralposition were more likely to have an asymmetric block (P <.05).CONCLUSIONSThe risk of prolonged deceleration after epiduralbupivacaine or intrathecal sufentanil labor analgesia is unrelatedto maternal position or analgesic technique.

Database: Medline

12. Positional effects on maternal cardiac output during laborwith epidural analgesia.

Author(s): Danilenko-Dixon, D R; Tefft, L; Cohen, R A; Haydon,B; Carpenter, M W

Source: American journal of obstetrics and gynecology; Oct 1996;vol. 175 (no. 4); p. 867-872

Publication Date: Oct 1996

Publication Type(s): Randomized Controlled Trial Clinical TrialJournal Article

Abstract:OBJECTIVEOur purpose was to test the hypothesis thatthe supine versus the lateral position is associated with a greaterdecrement in cardiac output after epidural analgesia in labor.STUDYDESIGNTwenty-one normal term subjects were randomized to the leftlateral or supine position in early labor. Cardiac output measuredby the acetylene rebreathing method, stroke volume, heart rate,mean arterial pressure, and systemic vascular resistance wereobtained at 5-minute intervals, beginning before a 500 mlintravenous fluid bolus (baseline) and ending 45 minutes afterepidural injection.RESULTSMean baseline supine versus lateral groupdifferences were significant for 21% lower cardiac output, 21%lower stroke volume, 19% higher mean arterial pressure, 50% highersystemic vascular resistance, and equivalent heart rate. In thesupine group fluid bolus resulted in significantly increasedcardiac output and stroke volume, decreased mean arterial pressureand systemic vascular resistance, and unchanged heart rate. In thesupine group cardiac output and stroke volume decreasedsignificantly after epidural injection. The lateral position groupexhibited no hemodynamic alterations after fluid bolus orepidural.CONCLUSIONSIn contrast to the lateral position, the supineposition is associated with a significant postepidural decrement incardiac output, not identified by a change in heart rate. Thislikely reflects an inability to maintain stable preload volume inthe supine position.

Database: Medline

13. Maternal positioning affects fetal heart rate changes afterepidural analgesia for labour.

Author(s): Preston, R; Crosby, E T; Kotarba, D; Dudas, H;Elliott, R D

Source: Canadian journal of anaesthesia = Journal canadiend'anesthesie; Dec 1993; vol. 40 (no. 12); p. 1136-1141

Publication Date: Dec 1993

Publication Type(s): Randomized Controlled Trial Clinical TrialJournal Article

Available in full text at Canadian Journal of Anesthesia/Journalcanadien d'anesth�sie - from Springer Link Journals

Available in full text at Canadian Journal of Anesthesia - fromFree Access Content

Abstract:Adverse fetal heart rate (FHR) changes suggestive offetal hypoxia are seen in patients with normal term pregnanciesafter initiation of epidural block for labour analgesia. It was ourhypothesis that, in some parturients, these changes were aconsequence of concealed aortocaval compression resulting indecreased uterine blood flow. We expected that the full lateralposition compared with the wedged supine position would providemore effective prophylaxis against aortocaval compression. To testour hypothesis we studied the role of maternal positioning on FHRchanges during onset of epidural analgesia for labour. Eighty-eightASA Class I or II term parturients were randomized into two groups:those to be nursed in the wedged supine position and those to benursed in the full lateral position during induction of an epiduralblock. External FHR monitoring was employed to assess the fetalresponse to initiation of labour epidural analgesia. Epiduralcatheters were sited with the parturients in the sitting positionand the patients then assumed the study position. After a negativetest dose, a standardized regimen of bupivacaine 0.25% was employedto provide labour analgesia. The quality and efficacy of the blockwere assessed using VAS pain scores,

http://linker2.worldcat.org/?rft.institution_id=129803&spage=1136&pkgName=customer.129803.8&issn=0832-610X&linkclass=to_article&jKey=12630&issue=12&date=1993-12&aulast=Preston%2C+R%3B+Crosby%2C+E+T%3B+Kotarba%2C+D%3B+Dudas%2C+H%3B+Elliott%2C+R+D&atitle=Maternal+positioning+affects+fetal+heart+rate+changes+after+epidural+analgesia+for+labour.&title=Canadian+Journal+of+Anesthesia%2FJournal+canadien+d%27anesth%EF%BF%BDsie&rft.content=fulltext%2Cprint&eissn=1496-8975&linkScheme=link.springer&jHome=http%3A%2F%2Flink.springer.com%2Fjournal%2F12630&volume=40&rft.id=info%3Apmid%2F&rft.order_by=preference&linktype=besthttp://linker2.worldcat.org/?jHome=http%3A%2F%2Fspringerlink.com%2Fcontent%2F0832-610x&linktype=best

motor block scores and sensory levels. The results demonstratedthat there was no difference in the quality of analgesia providednor in the incidence of asymmetric blocks. There was no differencein the observed incidence of FHR changes occurring during theinitiation of the epidural block.(ABSTRACT TRUNCATED AT 250WORDS)

Database: Medline

14. Epidural analgesia in labour and maternal posture.

Author(s): Rickford, W J; Reynolds, F

Source: Anaesthesia; Dec 1983; vol. 38 (no. 12); p.1169-1174

Publication Date: Dec 1983

Publication Type(s): Research Support, Non-u.s. Gov'tComparative Study Randomized Controlled Trial Clinical TrialJournal Article

Abstract:The effect of maternal position in the periodimmediately following epidural administration on analgesia and sideeffects was examined during labour. Patients were randomlyallocated to two groups and were either turned from left to rightlateral position within 5 minutes of bupivacaine administration (n= 35), or kept in the supine position, modified as appropriate,until pain relief or side effects indicated a change (n = 35).There was no significant difference between the two groups in onsetor duration of analgesia, the need for supplements or in absorptionof bupivacaine. Circulatory disturbances, all mild and transient,were seen in 14 patients (eight lateral, six supine). There was nosignificant difference between the two groups either in thefrequency of hypotension (four lateral, five supine) or of fetalheart deterioration (four lateral, three supine). However motorblock occurred in 15 of the lateral group and five supine (p lessthan 0.02). Such differences are not thought sufficient tocounterbalance the potential circulatory disadvantage of the supineposition.

Database: Medline

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