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Upright early labour lowers caesarean rate

Upright labour Staying upright during first stage labour reduces the chance of having a caesarean by 29 per cent, a new study has found.

An updated Cochrane Review of evidence on the topic provides the strongest evidence yet in favour of women staying upright during this stage of labour.

"We now have statistical significance of a 29 per cent less likelihood of having a caesarean birth," says first author, Annemarie Lawrence, who is a clinical research midwife at Townsville Hospital in Queensland.

The review compared upright positions (walking, sitting, standing and kneeling) with recumbent and semi-recumbant positions on the back or side.

Apart from the reduction in caesareans, it also found the duration of labour is shortened by 1 hour and 22 minutes when women remained upright, compared to if they were in recumbent positions.

And it found remaining upright meant women were 19 per cent less likely to have an epidural.

While the researchers call for better quality trials on the subject, on the basis of the current findings they 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".

Assistance of gravity

President of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), Professor Michael Permezel says the reduction in the rate of caesareans shown in the study was "a little surprising", and is likely to be not as great given better quality data.

"I think that needs closer looking at," he says.

But Permezel says in the light of the latest review, the RANZCOG guidelines on maternal activity during first stage labour, which currently state that walking does not reduce the need for caesareans, will need to be updated.

Permezel expects the review will encourage the use of wireless monitoring to maximise mobility of mothers and their babies during first stage labour.

"There are small but significant benefits to being mobile, more upright than lying down during the first stage of labour," he says.

"This is to be expected because the assistance of gravity puts the baby in the best possible position for subsequent birth."

Permezel says most women will move about in first stage labour if they don't have an epidural. However, Permezel adds that where there is easy access to epidurals, at least 50 per cent of women having their first baby will tend to choose an epidural.

Impact of epidurals

Professor Hannah Dahlen of the School of Nursing and Midwifery at the University of Western Sydney says it is "increasingly common" for women to be lying down once they are 5 centimetre dilated and this is usually because they have had an epidural.

This is especially the case in private hospitals, she says.

Dahlen also says 90 per cent of women have continuous electronic foetal monitoring strapped to them, which also encourages them to stay in bed.

She says her own ethnographic research has found that when women are in home-like environments, where a bed is not the main focus, they tend to be drawn to a forwards-leaning position in both first and second-stage labour.

"Birthing lying down is relatively modern phenomenon," says Dahlen.

Position for birth?

Permezel says there is not a lot of evidence to support which position is best during second stage labour and birth.

While squatting might seem most natural, he says most women find being in a semi-recumbent position enables gravity to act while giving some degree of comfort.

Permezel says there is no evidence that giving birth on all fours enhances labour.

"The baby has to go uphill in the all fours position. In theory, and I suspect in practice as well, the all fours position probably slows labour," he says.

Dahlen disagrees: "It's the opposite," she says.

Because of the shape of the vagina, she says, the passage of the baby is more 'down' than 'up' when women give birth on all fours.

In addition Dahlen says, being on all fours frees the woman to rock their hips to manoeuvre the baby down the birth canal.

"When you are lying on the bed your bum is pinned so you are not going to be wiggling it," she says.

"The all fours position was the one I found women instinctually took if they weren't directed to take another position."