The Effect of Labor Position during Second Stage of Labor on Mode of Delivery in Low Risk Women

Implementation of the Practice Programme for Upright Positions in the Second Stage of Labour and the birth experience of Chinese women: A qualitative study

Background: second stage of labor begins when the cervix is fully dilated and ends with the birth of a baby. The duration of second stage of labor commonly lasts 2 hours for primigravida mothers and one hour for multigravida mothers. Prolonged labor is one of complications experienced by mothers in second stage of labor. Prolonged labor can cause several complications for both mothers and infants. Prolonged labor can harm both the mother and the infant. The harmful effects of complications during second stage of labor for mothers include the incidence of uterine atony, laceration, bleeding, infection, fatigue and shock and improving the birth rate with the C-section incision. Whereas the harmful effects of complications during second stage of labor for infants include asphyxiated, cerebral trauma caused by pressure on the head of the fetus, the injury due to action, and premature rupture of membranes. The severity of the injury increases continuously along with the longer of the duration of the labor process, and the risk of which rises quickly after 24 hours. The longer the labor, the higher the morbidity as well as the mortality. The stage of labor affected by all such factors mentioned is called the second stage of laborObjective: to find out the relationship of parity, maternal age, and birth weight with the duration of the second stage of labor.Methods: this study applied a quantitative research design using an analytical survey method through a cross sectional approach. The sample in this study was chosen using total sampling method with the purposive sampling technique, namely, that the sample was all maternity mothers who were coincidentally present at the time of the study at UPTD Karya Mukti Public Health Center in August 2021. Then, Chi-square statistical test was used to determine the relationship between independent variables and dependent variable.Results: of the 30 respondents, 20 respondents whose parity was not at risk (95.2%) experienced normal duration of second stage of labor, while 5 respondents (55.6%) whose parity was at risk experienced normal duration of second stage of labor. 21 respondents whose maternal age was not at risk (95.5%) experienced normal duration of second stage of labor, while 4 respondents whose maternal age was at risk (50%) experienced normal duration second stage of labor. 23 respondents (92%) with normal birth weight babies experienced normal duration of second stage of labor, while 2 respondents (40%)with large birth weight babies experienced normal duration of second stage of labor. The results of the Chi-square statistical test showed that there was a significant relationship between parity and the duration of the second stage of labor with the p-value of 0.019 £ 0.05 and the OR value of 9.157. There was a significant relationship between maternal age and the duration of the second stage of labor with the p-value of 0.011 £ 0.05 and the OR value of 5.387, and there was a significant relationship between birth weight and the duration of the second stage of labor with the p-value of 0.022 £ 0.05 and OR value of 3.405.Conclusions: there was a relationship between parity and the duration of second stage of labor. There was a relationship between maternal age and the duration of second stage of labor, and there was a relationship between birth weight and the duration of second stage of labor. Suggestions: It is hoped that health workers will further improve IEC (Information, Education, and Communication) regarding safe gestational age, safe parity and balanced nutrition as a form of antenatal care for pregnant women which is very influential, especially during the second stage of labor. In addition, for pregnant women, it is better to perform quality ANC to predict whether mothers will be likely to experience prolonged labor or not and also to prevent prolonged labor and other complications of pregnancy and labor. Then, based on the results of ANC tests, the mothers immediately referred to a more adequate hospitals/maternity hospitals to monitor the condition of their pregnancy so as to prevent the risk that will be faced by the mothers and fetus during labor. Keywords: Parity, Maternal Age, Birth Weight, Duration of Second Stage Labor

Background: According to WHO (2018) 8% of maternal deaths are caused by prolonged labor. The long duration of the second stage of labor is one of the factors that cause prolonged labor. For this reason, oral intake is recommended to meet the needs of the mother during labor. Giving glucose and honey as an oral alternative during labor was chosen because the time needed to become energy is relatively fast so that it can be given to mothers during labor and can provide oral intake for mothers in labor to accelerate the second stage and prevent prolonged labor.
 Purpose: To determine the effectiveness of giving glucose and honey solution on the duration of the second stage of labor in Midwife’s Independent Practice
 Methods: This research is a quantitative research using a quasi-experimental design research method. 30 respondents based on inclusion criteria were divided into two groups and intervened with a solution of glucose and honey. The duration of the second stage of labor was observed for each respondent and analyzed through the unpaired T-Test. Results: The results of the unpaired T statistic test obtained a p-value of 0.021 (p-value <0.05). There were differences in the duration of the second stage of labor in respondents who were given honey and glucose solution. The average duration of the second stage of labor in the treatment group that was given honey was 5.14 minutes shorter than the group given the glucose solution. Conclusion: There is a difference in the duration of the second stage of primigravida labor in pregnant women who are given honey and glucose solution. Giving honey is more effective in accelerating the duration of the second stage of labor in primigravida at PMB Palembang in 2021

Background: According to WHO (2018) 8% of maternal deaths are caused by prolonged labor. The long duration of the second stage of labor is one of the factors that cause prolonged labor. For this reason, oral intake is recommended to meet the needs of the mother during labor. Giving glucose and honey as an oral alternative during labor was chosen because the time needed to become energy is relatively fast so that it can be given to mothers during labor and can provide oral intake for mothers in labor to accelerate the second stage and prevent prolonged labor.
 Purpose: To determine the effectiveness of giving glucose and honey solution on the duration of the second stage of labor in Midwife’s Independent Practice
 Methods: This research is a quantitative research using a quasi-experimental design research method. 30 respondents based on inclusion criteria were divided into two groups and intervened with a solution of glucose and honey. The duration of the second stage of labor was observed for each respondent and analyzed through the unpaired T-Test. Results: The results of the unpaired T statistic test obtained a p-value of 0.021 (p-value <0.05). There were differences in the duration of the second stage of labor in respondents who were given honey and glucose solution. The average duration of the second stage of labor in the treatment group that was given honey was 5.14 minutes shorter than the group given the glucose solution. Conclusion: There is a difference in the duration of the second stage of primigravida labor in pregnant women who are given honey and glucose solution. Giving honey is more effective in accelerating the duration of the second stage of labor in primigravida at PMB Palembang in 2021

For centuries, there has been controversy around whether being upright (sitting, birthing stools, chairs, squatting, kneeling) or lying down (lateral (Sim's) position, semi-recumbent, lithotomy position, Trendelenburg's position) have advantages for women giving birth to their babies. This is an update of a review previously published in 2012, 2004 and 1999. To determine the possible benefits and risks of the use of different birth positions during the second stage of labour without epidural anaesthesia, on maternal, fetal, neonatal and caregiver outcomes. We searched Cochrane Pregnancy and Childbirth's Trials Register (30 November 2016) and reference lists of retrieved studies. Randomised, quasi-randomised or cluster-randomised controlled trials of any upright position assumed by pregnant women during the second stage of labour compared with supine or lithotomy positions. Secondary comparisons include comparison of different upright positions and the supine position. Trials in abstract form were included. Two review authors independently assessed trials for inclusion and assessed trial quality. At least two review authors extracted the data. Data were checked for accuracy. The quality of the evidence was assessed using the GRADE approach. Results should be interpreted with caution because risk of bias of the included trials was variable. We included eleven new trials for this update; there are now 32 included studies, and one trial is ongoing. Thirty trials involving 9015 women contributed to the analysis. Comparisons include any upright position, birth or squat stool, birth cushion, and birth chair versus supine positions.In all women studied (primigravid and multigravid), when compared with supine positions, the upright position was associated with a reduction in duration of second stage in the upright group (MD -6.16 minutes, 95% CI -9.74 to -2.59 minutes; 19 trials; 5811 women; P = 0.0007; random-effects; I² = 91%; very low-quality evidence); however, this result should be interpreted with caution due to large differences in size and direction of effect in individual studies. Upright positions were also associated with no clear difference in the rates of caesarean section (RR 1.22, 95% CI 0.81 to 1.81; 16 trials; 5439 women; low-quality evidence), a reduction in assisted deliveries (RR 0.75, 95% CI 0.66 to 0.86; 21 trials; 6481 women; moderate-quality evidence), a reduction in episiotomies (average RR 0.75, 95% CI 0.61 to 0.92; 17 trials; 6148 women; random-effects; I² = 88%), a possible increase in second degree perineal tears (RR 1.20, 95% CI 1.00 to 1.44; 18 trials; 6715 women; I² = 43%; low-quality evidence), no clear difference in the number of third or fourth degree perineal tears (RR 0.72, 95% CI 0.32 to 1.65; 6 trials; 1840 women; very low-quality evidence), increased estimated blood loss greater than 500 mL (RR 1.48, 95% CI 1.10 to 1.98; 15 trials; 5615 women; I² = 33%; moderate-quality evidence), fewer abnormal fetal heart rate patterns (RR 0.46, 95% CI 0.22 to 0.93; 2 trials; 617 women), no clear difference in the number of babies admitted to neonatal intensive care (RR 0.79, 95% CI 0.51 to 1.21; 4 trials; 2565 infants; low-quality evidence). On sensitivity analysis excluding trials with high risk of bias, these findings were unchanged except that there was no longer a clear difference in duration of second stage of labour (MD -4.34, 95% CI -9.00 to 0.32; 21 trials; 2499 women; I² = 85%).The main reasons for downgrading of GRADE assessment was that several studies had design limitations (inadequate randomisation and allocation concealment) with high heterogeneity and wide CIs. The findings of this review suggest several possible benefits for upright posture in women without epidural anaesthesia, such as a very small reduction in the duration of second stage of labour (mainly from the primigravid group), reduction in episiotomy rates and assisted deliveries. However, there is an increased risk blood loss greater than 500 mL and there may be an increased risk of second degree tears, though we cannot be certain of this. In view of the variable risk of bias of the trials reviewed, further trials using well-designed protocols are needed to ascertain the true benefits and risks of various birth positions.

BackgroundIt is believed that giving birth in an upright position is beneficial for both mother and the infant for several physiologic reasons. An upright positioning helps the uterus to contract more strongly and efficiently, the baby gets in a better position and thus can pass through the pelvis faster. Upright and lateral positions enables flexibility in the pelvis and facilitates the extension of the outlet. Before implementing a change in birthing positions in our clinics we need to review evidences available and context valid related to duration of second stage of labor and birthing positions. Therefore this review aimed to examine the effect of maternal flexible sacrum birth position on duration of second stage of labor.MethodThe research searched articles using bibliographical Databases: Medline/PUBMED, SCOPUS, Google scholar and Google. All study designs were considered while investigating the impact of maternal flexible sacrum birthing positioning in relation duration of second stage of labor. Studies including laboring mothers with normal labor and delivery. A total of 1985 women were included in the reviewed studies. We included both qualitative and quantitative analysis.ResultsWe identified 1680 potential citations, of which 8 articles assessed the effect of maternal upright birth positioning on the reduction during the duration of second stage of labor. Two studies were excluded because of incomplete reports for meta analysis. The result suggested a reduction in duration of second stage of labor among women in a flexible sacrum birthing position, with a mean duration from 3.2–34.8. The pooled weighted mean difference with random effect model was 21.118(CI: 11.839–30.396) minutes, with the same significant heterogeneity between the studies (I2 = 96.8%, p < 000).ConclusionThe second stage duration was reduced in cases of a flexible sacrum birthing position. Even though the reduction in duration varies across studies with considerable heterogeneity, laboring women should be encouraged to choose her comfortable birth position. Researchers who aim to compare different birthing positions should consider study designs which enable women to choose birthing position.Prospero registration number[CRD42019120618]

Upright positions during the second stage of labour and birth outcomes: A prospective observational study.

For centuries, there has been controversy around whether being upright (sitting, birthing stools, chairs, squatting, kneeling) or lying down have advantages for women delivering their babies. To assess the benefits and risks of the use of different positions during the second stage of labour (i.e. from full dilatation of the uterine cervix). We searched the Cochrane Pregnancy and Childbirth Group Trials Register (28 February 2012). Randomised or quasi-randomised controlled trials of any upright or lateral position assumed by pregnant women during the second stage of labour compared with supine or lithotomy positions. Secondary comparisons include comparison of different upright positions and the lateral position. Two review authors independently assessed trials for inclusion and assessed trial quality. At least two review authors extracted the data. Data were checked for accuracy. Results should be interpreted with caution as the methodological quality of the 22 included trials (7280 women) was variable.In all women studied (primigravid and multigravid) there was a non-significant reduction in duration of second stage in the upright group (mean difference (MD) -3.71 minutes; 95% confidence interval (CI) -8.78 to 1.37 minutes; 10 trials, 3485 women; random-effects, I(2) = 94%), a significant reduction in assisted deliveries (risk ratio (RR) 0.78; 95% CI 0.68 to 0.90; 19 trials, 6024 women, I(2)= 27%), a reduction in episiotomies (average RR 0.79, 95% CI 0.70 to 0.90, 12 trials, 4541 women; random-effects, I(2) = 7%), an increase in second degree perineal tears (RR 1.35; 95% CI 1.20 to 1.51, 14 trials, 5367 women), increased estimated blood loss greater than 500 ml (RR 1.65; 95% CI 1.32 to 2.60; 13 trials, 5158 women, asymmetric funnel plot indicating publication bias), fewer abnormal fetal heart rate patterns (RR 0.46; 95% CI 0.22 to 0.93; two trials, 617 women). In primigravid women the use of any upright compared with supine positions was associated with: non-significant reduction in duration of second stage of labour (nine trials: mean 3.24 minutes, 95% CI 1.53 to 4.95 minutes) - this reduction was largely due to women allocated to the use of the birth cushion. The findings of this review suggest several possible benefits for upright posture in women without epidural, but with the possibility of increased risk of blood loss greater than 500 mL. Until such time as the benefits and risks of various delivery positions are estimated with greater certainty, when methodologically stringent data from trials are available, women should be allowed to make choices about the birth positions in which they might wish to assume for birth of their babies.

A randomised controlled trial in comparing maternal and neonatal outcomes between hands-and-knees delivery position and supine position in China

Objective To investigate the association between the duration of second stage of labor and maternal and neonatal outcomes in pregnant women complicated with hypertensive disorders, dysglycaemia (including gestational diabetes mellitus and diabetes mellitus complicating pregnancy) or primipara-in-advanced-age, and in normal pregnant women after implementation of new partogram. Methods A retrospective analysis was performed on all nulliparous women with the duration of second stage of labor≥ 2 h at Beijing Obstetrics and Gynecology Hospital, Capital Medical University between October 1, 2014 and March 31, 2015. Women with preterm labor, multiple gestation, noncephalic presentations, fetal malformations, placenta previa, or induction of labor after fetal death were excluded. And 279 women who met the inclusion criteria served as study group. Among the 279 women, 25 had hypertensive disorders (hypertension group), 46 had dysglycaemia (dysglycaemia group), and 35 had primipara-in-advanced-age (primipara-in-advanced-age group), and the remaining 177 women served as ordinary study group. According to the duration of second stage, the ordinary study group was divided into three subgroups: ≥2-<2.5 h (n=90), ≥2.5-<3 h (n=51) , and ≥3 h (n=36). And 340 women with the duration <2 h were selected randomly as control group, including 24 with hypertensive disorders (hypertension control group), 61 with dysglycaemia (dysglycaemia control group), and 41 with primipara-in-advanced-age (primipara-in-advanced-age control group); the remaining 226 women served as ordinary control group. Maternal and neonatal outcomes in these two groups were analyzed with Rank sum test, Chi-square test or Fisher's exact test. Results (1) Dysglycaemia group had a longer first stage of labor, lower rate of spontaneous labor and higher rate of forcep-assisted delivery than its counterpart control group [11.88(8.42-16.06) vs 8.17(5.00-14.12) h, 67.4%(31/46) vs 91.8%(56/61), and 30.4%(14/46) vs 8.2%(5/61), respectively, all P 3 h subgroup had a longer first stage of labor, higher labor intervention rate, and lower spontaneous labor rate (all P<0.05). Ordinary study group and ≥3 h subgroup had higher rates of labor analgesia and forcep-assisted delivery than the ordinary control group. The forcep-assisted delivery rate in ≥2.5-<3 h subgroup and cesarean section rate in ≥3 h subgroup were all higher than in ordinary control group (P<0.05). (2) Hypertension group had a higher incidence of postpartum hemorrhage than its corresponding control group while primipara-in-advanced-age group had a higher incidence [48.0%(12/25) vs 20.8%(5/24), and 34.3%(12/35) vs 7.3%(3/41), both P<0.05). Ordinary study group, ≥2.5-<3 h subgroup and ≥3 h subgroup had higher rates of postpartum hemorrhage and adverse wound healing than the ordinary control group (all P<0.05). (3) Compared with ordinary control group, ≥2-<2.5 h subgroup had a higher rate of neonatal asphyxia, ≥2.5-<3 h subgroup had higher fetal macrosomia proportion, and ≥3 h subgroup had a higher rate of admission to neonatal intensive care unit (all P<0.05). In ordinary study group, 6(3.4%) out of the 177 cases had neonatal asphyxia, all in the ≥2-<2.5 h subgroup [6.7%(6/90)], which was higher than in the ordinary control group [0.9% (2/226)], P<0.05. Conclusions With the prolonged duration of the second stage, the risk of adverse maternal and neonatal outcomes increases. For pregnant women complicated with hypertensive disorders, dysglycaemia or primipara-in-advanced-age, the duration of the second stage of should not be prolonged. Key words: Labor stage, second; Pregnancy outcome; Hypertension, pregnancy-induced; Glucose metabolism disorders; Parity

BackgroundWe sought to investigate the impact of the duration of second stage of labor on risk of severe perineal lacerations (third and fourth degree).MethodsThis population based cohort study was conducted in the Stockholm/Gotland region, Sweden, 2008–2014. Study population included 52 211 primiparous women undergoing vaginal delivery with cephalic presentation at term. Unconditional logistic regression analysis was used to calculate crude and adjusted odds ratios (OR), using 95% confidence intervals (CI). Main exposure was duration of second stage of labor, and main outcome was risks of severe perineal lacerations (third and fourth degree).ResultsRisk of severe perineal lacerations increased with duration of second stage of labor. Compared with a second stage of labor of 1 h or less, women with a second stage of more than 2 h had an increased risk (aOR 1.42; 95% CI 1.28–1.58). Compared with non-instrumental vaginal deliveries, the risk was elevated among instrumental vaginal deliveries (aOR 2.24; 95% CI 2.07–2.42). The risk of perineal laceration increased with duration of second stage of labor until less than 3 h in both instrumental and non-instrumental vaginal deliveries, but after 3 h, the ORs did not further increase. After adjustments for potential confounders, macrosomia (birth weight > 4 500 g) and occiput posterior fetal position were risk factors of severe perineal lacerations.ConclusionsThe risk of severe perineal laceration increases with duration until the third hour of second stage of labor. Instrumental delivery is the most significant risk factor for severe lacerations, followed by duration of second stage of labor, fetal size and occiput posterior fetal position.

BackgroundProlonged second stage of labour has been associated with adverse maternal and perinatal outcomes. The maximum length of the second stage from full dilatation to birth of the baby remains controversial. Our aim was to determine whether extending second stage of labour was associated with adverse maternal and perinatal outcomes.MethodsA retrospective cohort study was conducted using routinely collected hospital data from 51592 births in Aberdeen Maternity Hospital between 2000 and 2016. The hospital followed the local guidance of allowing second stage of labour to extend by an hour compared to national guidelines since 2008 (nulliparous and parous). The increasing duration of second stage of labour was the exposure. Baseline characteristics, maternal and perinatal outcomes were compared between women who had a second stage labour of (a) ≤ 3 h and (b) > 3 h duration for nulliparous women; and (a) ≤ 2 h or (b) > 2 h for parous women. An additional model was run that treated the duration of second stage of labour as a continuous variable (measured in hours). All the adjusted models accounted for: age, BMI, smoking status, deprivation category, induced birth, epidural, oxytocin, gestational age, baby birthweight, mode of birth and parity (only for the final model).ResultsEach hourly increase in the second stage of labour was associated with an increased risk of obstetric anal sphincter injury (aOR 1.21 95% CI 1.16,1.25), having an episiotomy (aOR 1.48 95% CI 1.45, 1.52) and postpartum haemorrhage (aOR 1.27 95% CI 1.25, 1.30). The rates of caesarean and forceps delivery also increased when second stage duration increased (aOR 2.60 95% CI 2.50, 2.70, and aOR 2.44 95% CI 2.38, 2.51, respectively.) Overall adverse perinatal outcomes were not found to change significantly with duration of second stage on multivariate analysis.ConclusionsAs the duration of second stage of labour increased each hour, the risk of obstetric anal sphincter injuries, episiotomies and PPH increases significantly. Women were over 2 times more likely to have a forceps or caesarean birth. The association between adverse perinatal outcomes and the duration of second stage of labour was less convincing in this study.

The second stage of labour has traditionally been managed by the midwife, directing women how and when to push. This usually involves women being instructed to use the Valsalva manoeuvre within prescribed time limits in supine or lithotomy positions. The rationale is that the duration of second stage of labour is reduced and therefore the risks of adverse effects to mother and fetus minimised. However, there is accumulating evidence that directed pushing within arbitrary time limits in supine positions is disadvantageous to the woman and fetus and is actually unjustified. Spontaneous pushing, which allows the woman to follow her own instincts and push in the second stage of labour, does not put the women or the fetus at risk of adverse effects. On the contrary, it offers clear benefits to both. Furthermore, the woman should be allowed to adopt positions that are most comfortable for her, yet encourage fetal rotation and descent through the maternal pelvis. The positions adopted can be variable, as long as labour is progressing, although upright positions are advocated during the second stage of labour compared to supine positions, which are not recommended.

Soft-tissue dystocia due to paradoxical contraction of the levator ani as a cause of prolonged second stage: concept, diagnosis, and potential treatment

Labour is a physiological process. Before the seventeenth century, the upright birthing position was common in western countries. The supine position became popular because of the convenience for health professionals rather than the benefits for women. To compare the outcomes of normal deliveries between squatting and lying down positions and to assess the risks and benefits of squatting position during the second and third stages of labour and its comparison with the lying down position. A hospital-based prospective randomized controlled study was conducted in the Department of Obstetrics and Gynaecology in tertiary care centre carried over a period of 18months among 212 female patients in labour assigned in Group A squatting position and Group B lying down position. The mean age of patients in Group A was 23.30 ± 4.30years and Group B was 23.81 ± 4.13years. The mean duration of second and third stages of labour in both multigravida and primigravida patients was significantly lower in Group A (p < 0.05). The mean amount of blood loss in Group A was significantly higher compared to Group B (p < 0.05). The mean VAS score assessing severity of pain at second stage and third stage of labour was significantly lower in Group A compared to Group B (p < 0.05). Squatting position was found much convenient for mothers in terms of less duration of second stage of labour, less number of patients administered oxytocin, lesser extension of episiotomy and greater maternal satisfaction on severity of pain.