Maternal Position During the First Stage of Labor: A Systematic Review

Abstract & Research

Background
Policy makers and health professionals are progressively using evidence-based rationale to guide their decisions. There has long been controversy regarding which maternal position is more appropriate during the first stage of labor. This problem has been examined often and repeatedly and the optimal recommendation remains unclear.

Methods
This is a systematic review of the effect of maternal position during the first stage of labor. The main question addressed here is: Does encouraging women to adopt an upright position or to ambulate during the first stage of labor reduce the duration of this stage? All randomized controlled trials carried out to assess this effect were taken into consideration in this review. The following electronic databases were accessed to identify studies: MEDLINE, Popline, the Scientific Electronic Library On-line and the Latin American and Caribbean Health Science Information. Citation eligibility was independently assessed by two reviewers. The methodological quality of each trial was also evaluated independently by two reviewers and a trial under consideration was included only when consensus had been attained. Allocation concealment and screening for the occurrence of attrition, performance and detection biases were considered when studies were appraised. The decision whether to perform data pooling was based on the clinical similarity of studies.

Results
The search strategy resulted in 260 citations, of which 18 were assessed in full-text. Nine eligible randomized controlled trials were included in the systematic review. Randomization methods were not fully described in eight studies. The allocation concealment was considered adequate in four studies and unclear in five. The investigators pooled the data from seven studies in which the length of the first stage of labor and results were in favor of the intervention, but the high level of heterogeneity (I2 = 88.4%) impaired the meaning of this finding. The intervention did not affect other outcomes studied (mode of delivery, use of analgesia, labor augmentation and condition of the child at birth).

Conclusion
Adoption of the upright position or ambulation during first stage of labor may be safe, but considering the available evidence and its consistency, it cannot be recommended as an effective intervention to reduce duration of the first stage of labor.

Background
Even before the development of modern obstetrics, controversy existed with respect to maternal position during labor. The horizontal position during the first stage of labor is believed to have been introduced by Mauriceau in the 18^th century to facilitate the care of women and the performance of obstetric maneuvers and procedures [1]. The horizontal position was thus incorporated into Western culture as the standard position during labor. Nevertheless, the standardization of this position for labor was never fully accepted, and more than two centuries ago there were those who advocated the value of not confining women in labor to bed [2]. In fact, in most cultures that have not been influenced by this Western custom, women in labor continue to opt for the upright position or to keep ambulating [1].

Throughout the scientific development of obstetrics, this controversy has been examined several times under different perspectives. From the physiological standpoint, the supine position has been observed to be associated with the compression of abdominal blood vessels and impairment of fetal nutrition and oxygenation [3]. It has also been argued that this position would negatively interfere with uterine contractions [4]. However, upright position during first stage of labor may improve maternal comfort and reduce the need for analgesia [5]. In this context, labor without bed confinement became part of a set of actions involved in promoting the empowerment of women and the humanization of labor. In accordance with these views, an argument was built in favor of the upright position during labor.

On the other hand, over the past twenty years, policy makers, health professionals and even the lay society are progressively using an evidence-based rationale to guide their decisions. A considerable amount of knowledge had already been accumulated on the subject more than twenty years ago, and the remaining facts available today have been acquired over that interval of time. In summary, the purpose of the adoption of an upright position has been the enhancement of uterine contractions and fetal condition, and the promotion of maternal comfort [3-5]. Nevertheless, although the issue has frequently been examined, the optimal alternative remains unclear. For this reason, it was decided to carry out a systematic review with the objective of assessing the effect of adopting the upright position or ambulating during the first stage of labor on selected obstetrical and perinatal outcomes.

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