Lawrence Annemarie, Lewis Lucy, Hofmeyr G Justus, Styles Cathy
Health & Well Being Service Group and Tropical Health Research Unit for Nursing and Midwifery Practice, The Townsville Hospital and Health Service, Douglas, Queensland, Australia, 4810.
Cochrane Database Syst Rev. 2013 Aug 20(8):CD003934. doi: 10.1002/14651858.CD003934.pub3.
It is more common for women in both high- and low-income countries giving birth in health facilities, to labour in bed. There is no evidence that this is associated with any advantage for women or babies, although it may be more convenient for staff. Observational studies have suggested that if women lie on their backs during labour this may have adverse effects on uterine contractions and impede progress in labour, and in some women reduce placental blood flow.
To assess the effects of encouraging women to assume different upright positions (including walking, sitting, standing and kneeling) versus recumbent positions (supine, semi-recumbent and lateral) for women in the first stage of labour on duration of labour, type of birth and other important outcomes for mothers and babies.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2013).
Randomised and quasi-randomised trials comparing women randomised to upright versus recumbent positions in the first stage of labour.
We used methods described in the Cochrane Handbook for Systematic Reviews of Interventions for carrying out data collection, assessing study quality and analysing results. Two review authors independently evaluated methodological quality and extracted data for each study. We sought additional information from trial authors as required. We used random-effects analysis for comparisons in which high heterogeneity was present. We reported results using the average risk ratio (RR) for categorical data and mean difference (MD) for continuous data.
Results should be interpreted with caution as the methodological quality of the 25 included trials (5218 women) was variable.For Comparison 1: Upright and recumbent positions versus recumbent positions and bed care, the first stage of labour was approximately one hour and 22 minutes shorter for women randomised to upright as opposed to recumbent positions (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 were upright 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 to have an epidural (RR 0.81, 95% CI 0.66 to 0.99, nine studies, 2107 women; random-effects, T(2) = 0.02, I(2) = 61%). Babies of mothers who were upright were less likely to be admitted to the neonatal intensive 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 no significant differences between groups for other outcomes including duration of the second stage of labour, or other outcomes related to the well being of mothers and babies.For Comparison 2: Upright and recumbent positions versus recumbent positions and bed care (with epidural: all women), there were no significant differences between groups for outcomes including duration of the second stage of labour, or other outcomes related to the well being of mothers and babies.
AUTHORS' CONCLUSIONS: There is clear and important evidence that walking and upright positions in the first stage of labour reduces the duration of labour, the risk of caesarean birth, the need for epidural, and does not seem to be associated with increased intervention or negative effects on mothers' and babies' well being. Given the great heterogeneity and high performance bias of study situations, better quality trials are still required to confirm with any confidence the true risks and benefits of upright and mobile positions compared with recumbent positions for all women. Based on the current findings, we recommend that women in low-risk labour should be informed of the benefits of upright positions, and encouraged and assisted to assume whatever positions they choose.
在高收入和低收入国家，在医疗机构分娩的女性更常在产床上分娩。没有证据表明这对女性或婴儿有任何益处，尽管这对医护人员可能更方便。观察性研究表明，如果女性在分娩时仰卧，可能会对子宫收缩产生不利影响，阻碍产程进展，并且在一些女性中会减少胎盘血流。
评估鼓励处于第一产程的女性采用不同直立姿势（包括行走、坐、站和跪）与卧位姿势（仰卧、半卧和侧卧）相比，对产程时长、分娩类型以及对母亲和婴儿的其他重要结局的影响。
我们检索了Cochrane妊娠与分娩组试验注册库（2013年1月31日）。
比较在第一产程中被随机分配到直立姿势与卧位姿势的女性的随机试验和半随机试验。
我们使用Cochrane干预性系统评价手册中描述的方法进行数据收集、评估研究质量和分析结果。两位综述作者独立评估方法学质量并为每项研究提取数据。我们根据需要向试验作者寻求更多信息。对于存在高度异质性的比较，我们使用随机效应分析。我们使用分类数据的平均风险比（RR）和连续数据的平均差值（MD）报告结果。
由于纳入的25项试验（5218名女性）的方法学质量参差不齐，结果应谨慎解读。对于比较1：直立和卧位姿势与卧位姿势及卧床护理，被随机分配到直立姿势而非卧位姿势的女性，第一产程大约短1小时22分钟（平均MD -1.36，95%置信区间（CI）-2.22至-0.51；15项研究，2503名女性；随机效应，T(2)=2.39，Chi(2)=203.55，自由度=14，(P<0.00001)，I(2)=93%）。采用直立姿势的女性剖宫产的可能性也较小（RR 0.71，95%CI 0.54至0.94；14项研究，2682名女性），接受硬膜外麻醉的可能性也较小（RR 0.81，95%CI 0.66至0.99，9项研究，2107名女性；随机效应，T(2)=0.02，I(2)=61%）。采用直立姿势的母亲所生婴儿入住新生儿重症监护病房的可能性较小，然而这仅基于一项试验（RR 0.20，95%CI 0.04至0.89，1项研究，200名女性）。在其他结局方面，包括第二产程时长或与母亲和婴儿健康相关的其他结局，两组之间没有显著差异。对于比较2：直立和卧位姿势与卧位姿势及卧床护理（使用硬膜外麻醉：所有女性），在包括第二产程时长或与母亲和婴儿健康相关的其他结局方面，两组之间没有显著差异。
有明确且重要的证据表明，在第一产程中行走和采用直立姿势可缩短产程、降低剖宫产风险、减少硬膜外麻醉的需求，并且似乎与增加干预或对母亲和婴儿健康产生负面影响无关。鉴于研究情况存在很大的异质性和较高的执行偏倚，仍需要质量更高的试验来确定与卧位姿势相比，直立和活动姿势对所有女性的真正风险和益处。基于目前的研究结果，我们建议应告知低风险分娩的女性直立姿势的益处，并鼓励和协助她们采取任何自己选择的姿势。
