A meta-analysis of upright positions in the second stage to reduce instrumental deliveries in women with epidural analgesia

Background. Epidural analgesia is associated with an increased risk of instrumental delivery. We, in this study, present a systematic review in order to assess the effectiveness of maintaining an upright position during the second stage of labor to reduce instrumental deliveries among women choosing epidural analgesia. The study population included women with uncomplicated pregnancies at term with epidural analgesia established in the first stage of labor. Methods. We searched MEDLINE, EMBASE, and CINAHL databases and the Cochrane Trials Register up to July 2003 and cross‐checked the reference lists of published studies. Trial eligibility and outcomes were pre‐specified. Group tabular data were obtained for each trial and were analyzed by using meta‐analytic techniques. Results. Only two studies were included with data on 281 women (166 upright and 115 recumbent). Upright positions in the second stage were associated with a non‐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 in labor duration associated with upright positions. Data on other outcomes, including perineal trauma, postpartum hemorrhage, maternal satisfaction, and infant well‐being, were insufficient. Conclusions. There were insufficient data to show a significant benefit from upright positions in the second stage of labor for women who choose epidural or to evaluate safety aspects. However the magnitude of the reductions in instrumental delivery and cesarean section warrants an adequately powered randomized, controlled trial to fully evaluate the practice of upright positions in the second stage for women with an epidural.