compilation « positions d’accouchementmax.bonobo.free.fr/calin/positions.pdf · (telemetry)...

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Compilation

« Positions d’accouchement »

Base de données de l’AFARhttp://afar.info

Etude réalisée le 23 mai 2005

Source et mises à jour de ce document : http://afar.info/compilations/positions-compil.pdf

Compilation

« Positions d’accouchement »

Méthode de travail : Nous avons sélectionné 98 fiches parmi les 160 contenant lemot-clé « Position en cours de travail » dans la base de données de l’AFAR, le 23 mai2004. La base peut être interrogée directement à partir de la pagehttp://afar.info/biblio-liens.htm

Convention : Le numéro entre [crochets] est celui de la fiche dans la base de données.

La positionverticale et ladéambulation pendantle travailcontribuent à unemeilleureoxygénation du bébé.

[843] INTRODUCTION: Upright or ambulatory birthpositions are favorable for fetal oxygenation.Studies of fetal oxygenation with regard tomaternal position require free maternal mobility.Therefore, telemetry for a fetal sensor for suchinvestigations is a pre-requisite. Telemetry—iftechnically feasible—could enable monitoring offetal oxygen partial pressure using an existingsensor without restricting the mobility of theparturient woman. We have developed a telemetrysystem for use with a fetal transcutaneous partialoxygen pressure sensor (ttcpO2) and have studiedeffects of maternal position and position changesduring normal labor.

MATERIALS AND METHODS: The monitoring systemconsists of three parts: the telemetry unit withthe ttcpO2 sensor to transmit the tcpO2 and theheating output telemetrically, a modified CTGmonitor and a personal computer storing themeasurements. All data were plotted on the CTGrecording paper and fed into a new purpose-designedsoftware, displaying fetal heart rate, the uterinecontraction intensity, ttcpO2 and the heatingoutput. Three laboring women, randomly andsuccessively adopting classical birth positions(supine or side positions), sitting or vertical orwalking position, were studied.

RESULTS: Fetal heart rate, uterine contractions,ttcpO2 and heating output are influenced by thebirth positions and by changes of the birthposition. In the classical supine and side positionthere seemed to be lower fetal oxygenation.Sitting, standing and especially walking were morefavorable.

DISCUSSION: Telemetry is useful to study a possibleclinical benefit of individual birth positions.

Braun T, Sierra F, Seiler D, Mainzer K,Wohlschlager M, Tutschek B, Schmidt S. Continuoustelemetric monitoring of fetal oxygen partial

Compilation « Positions d’accouchement » ………… 2

Alliance Francophone pour l’Accouchement Respecté <http://afar.info>

pressure during labor. Archives of Gynecology andObstetrics 2004;270(1):40-45.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15205977

Remarques :Article en accès libre.

Pour les femmes souspéridurale, laposition endécubitus latéralserait plusbénéfique que laposition assise avecsoutien.

[848] Objective:

To determine whether the rate of instrumental birthin nulliparous women using epidural analgesia isaffected by maternal position in the passive secondstage of labour.

Design:

A pragmatic prospective randomised trial.

Setting:

Consultant maternity unit in the Midlands.

Participants:

One hundred and seven nulliparous women usingepidural analgesia and reaching the second stage oflabour with no contraindications to spontaneousbirth.

Interventions:

The lateral versus the supported sitting positionduring the passive second stage of labour.

Measurements:

Mode of birth, incidence of episiotomy, andperineal suturing.

Findings:

recruitment was lower than anticipated (107 vs. 220planned). Lateral position was associated withlower rates of instrumental birth rate (lateralgroup 33%; sitting group 52%; p=0.05, RR 0.64, CIfor RR: 0.40–1.01; Number-needed-to-treat (NNT)=5),of episiotomy (45% vs. 64%; p=0.05, RR 0.66, CI forRR: 0.44–1.00, NNT=5), and of perineal suturing(78% vs. 86%; p=0.243, RR 0.75, CI for RR0.47–1.17). The odds ratio for instrumental birthin the sitting group was 2.2 (CI 1.00–4.6).Logistic regression of potential confoundervariables was undertaken, due to a large variationin maternal weight between the randomised groups.Of the nine possible confounders tested, onlyposition of the baby's head at full dilationaffected the risk of instrumental birth



significantly (p=0.4, OR 2.7 where the fetal headwas in the lateral or posterior position). Maternalweight did not appear to have any effect. The oddsratio for instrumental delivery for womenrandomised to the sitting position was slightlyhigher within the logistic regression model(adjusted OR 2.3).

Key conclusions:

Women randomised to the lateral position had abetter chance of a spontaneous vaginal birth thanthose randomised to the supported sitting position.Position of the babys’ head at full dilation had anadditional effect on mode of birth. These effectsare not conclusively generalisable.

Recommendations for practice:

The lateral position is likely to be at bestbeneficial, and at the worst no less harmful thanthe sitting position for most women and theirbabies who meet the criteria set for this study.Conclusive evidence for or against the techniqueshould be established using larger trials.

Downe S, Gerrett D, Renfrew MJ. A prospectiverandomised trial on the effect of position in thepassive second stage of labour on birth outcome innulliparous women using epidural analgesia.Midwifery 2004;20(2):157-168.

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WN9-4BDY5VM-1&_user=10&_handle=B-WA-A-W-AE-MsSAYVW-UUW-AUEWVZAUBU-AUEUUVAYBU-CWUYDBZZA-AE-U&_fmt=summary&_coverDate=06%2F30%2F2004&_rdoc=6&_orig=browse&_srch=%23toc%236957%232004%23999799997%23503897!&_cdi=6957&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=70f8e1f1cc94abb2f746a1fff6b63b20

Cet article étudiela validitéd'opinions établiessur le bénéfice dela mobilité pendantle travail et passeen revue lestendences actuellesd'anesthésieambulatoires.

[1086] A simple statement that describes the degreeof the patient's satisfaction with the pain relieffrom her labor epidural analgesia has oftenassessed the quality of labor analgesia asperceived by the patient. Many laboringparturients, midwives, obstetricians andanesthesiologists are increasingly concerned by thelimitations of traditional epidural laboranalgesia. In general, women dislike the inabilityto void, the often-dense motor block, the feelingof numbness of the lower body, the total lack ofthe urge to bear down, and the complete perinealanesthesia. Continuous search for balanced laboranalgesia that provides relief from pain, whilepreserving motor function, has led to thedevelopment of an ambulatory labor analgesiatechnique. This article assesses the validity ofvarious strongly advocated opinions as to whether



parturients benefit from ambulation in labor andalso reviews the current trends in ambulatory laboranalgesia.

Kuczkowski KM. Ambulatory labor analgesia: whatdoes an obstetrician need to know?Acta Obstetricia et Gynecologica Scandinavica83(5):415-424.

http://www.blackwell-synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=0001-6349&date=2004&volume=83&issue=5&spage=415

Remarques :

Conclusions de l'article: Ambulatory laboranalgesia has become a popular choice of laboranalgesia for many parturients. Ambulation in laboris commonly believed to be of value in theestablishment and progression of labor, as well asincreasing maternal satisfaction and improvingneonatal outcome (83). In summary, the purportedadvantages of ambulation in the upright positionduring labor include enhancement of the pelvicdiameter, increased coordination, frequency andintensity of uterine contractions, increasedmaternal comfort and satisfaction and improvedneonatal outcome (higher Apgar scores), decreasedperception of labor pain, decreased need for laboraugmentation, and decreased requirements for laboranalgesia (1,84– 86). Although the effect ofambulation in labor on the progress of labor isstill under investigation, the ability to walk tothe bathroom and change positions in bed arecompelling enough as reasons in support of‘‘walking epidurals.’’ A laboring parturient shouldnever walk alone, a support person (deliveryroomnurse) and the ability tomonitor the fetus(telemetry) allow for ambulation in labor to besafe for both the mother and the fetus (83,86).

Bien que nepermettant pas untravail plus courtni une réduction desdouleurs, lamobilité pendant letravail sembleprésenter desavantages.

[1087] Ambulation during labor is becoming morepopular, although its impact on the progress oflabor and on pain intensity remains unclear. Wewondered whether prolonged ambulation with epiduralanalgesia had a possible effect on duration oflabor and pain. In this prospective, randomizedtrial, 61 parturients with uncomplicated termpregnancies were allocated to be recumbent (n = 31)or to ambulate (n = 30). Epidural analgesia wasprovided with intermittent administrations of 0.08%bupivacaine-epinephrine plus 1 mug/mL ofsufentanil. Of the 30 women assigned to theambulatory group, 25 actually walked. Theirambulating time was 64 +/- 34 min (mean +/- SD),i.e., 29% +/- 16% of the first stage. There were nodifferences between the two groups in the length oflabor and in pain visual analog scale scores.



However, the ambulatory group received smallerdoses of bupivacaine (6.4 +/- 2.2 mg/h versus 8.4+/- 3.6 mg/h; P = 0.01) and of oxytocin (6.0 +/-3.7 mUI/ min versus 10.2 +/- 8.8 mUl/min; P <0.05). A greater ability to void was also found inthe ambulatory group (P < 0.01). Although theduration of labor and pain relief was unchanged,these findings support that ambulation during labormay be advantageous.

Frenea S, Chirossel C, Rodriguez R, Baguet JP,Racinet C, Payen JF. The effects of prolongedambulation on labor with epidural analgesia.Anesthesia and Analgesia 98(1):224-229.


En Tanzanie, lesfemmes bougent peupendant le travailet choisissent lapositionlithotomique… parcequ'elles ignorentqu'il existed'autresalternatives.

[1098] BACKGROUND: Emerging research evidencesuggests a potential benefit in being upright inthe first stage of labour and a systematic reviewof trials suggests both benefits and harmfuleffects associated with being upright in the secondstage of labour. Implementing evidence-basedobstetric care in African countries with scarceresources is particularly challenging, and requiresan understanding of the cumulative nature ofscience and commitment to applying the most up todate evidence to clinical decisions. In this study,we documented current practice rates, explored thebarriers and opportunities to implementing theseprocedures from the provider perspective, anddocumented women's preferences and satisfactionwith care.

METHODS: This was an exploratory study usingquantitative and qualitative methods. Practicerates were determined by exit interviews with aconsecutive sample of postnatal women. Providerviews were explored using semi-structuredinterviews (with doctors and traditional birthattendants) and focus group discussions (withmidwives). The study was conducted at fourgovernment hospitals, two in Dar es Salaam and twoin the neighbouring Coast region, Tanzania.

MAIN OUTCOME MEASURES: Practice rates for mobilityduring labour and delivery position; women'sexperiences, preferences and views about the careprovided; and provider views of current practiceand barriers and opportunities to evidence-basedobstetric practice.

RESULTS: Across all study sites more women weremobile at home (15.0%) than in the labour ward(2.9%), but movement was quite restricted at homebefore women were admitted to labour ward (51.6%chose to rest with little movement). Supineposition for delivery was used routinely at all



four hospitals; this was consistent with women'spreferred choice of position, although very fewwomen are aware of other positions. Qualitativefindings suggest obstetricians and midwivesfavoured confining to bed during the first stage oflabour, and supine position for delivery.

CONCLUSIONS: The barriers to change appear to becomplicated and require providers to want tochange, and women to be informed of alternativepositions during the first stage of labour anddelivery. We believe that highlighting the gapbetween actual practice and current evidenceprovides a platform for dialogue with providers toevaluate the threats and opportunities for changingpractice.

Lugina H, Mlay R, Smith H. Mobility and maternalposition during childbirth in Tanzania: anexploratory study at four government hospitals.BMC Pregnancy Childbirth. 2004 Feb 19;4(1):3.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=15113446

Remarques :Texte en acces libre.

Revue Cochrane, dontla conclusion estd'encourager lesfemmes à choisir laposition danslaquelle elles sesentent le mieux.

[1099] CONTEXTE: La controverse autour desavantages des différentes positions d'accouchement,verticales (assise, bancs, sièges, quatre pattes),ou allongées, dure depuis des siècles.

OBJECTIFS: Déterminer les bénéfices et les risquesde différentes positions lors du second stade dutravail (i.e. à partir de la dilatation totale ducol).

STRATEGIE DE RECHERCHE: Trials enregistrés dans legroupe Cochrane Grossesse et Accouchement.

CRITERES DE SELECTION: Trials randomisés ou quasi-randomisés, ayant effectué un suivi adéquat etcomparant diverses positions utilisées par lesfemmes au second stade du travail.

RECUEIL DES DONNEES ET ANALYSE: Nous avonsindependemment estimé la qualité des trials pourles inclure dans cette étude, et extrait lesdonnées.

PRINCIPAUX RESULTATS: Les résultats doivent êtreinterprétés avec précaution car la qualité des 19trials inclus (5764 personnes) était variable.L'utilisation de n'importe quelle positionverticale ou en décubitus latéral, comparé audécubitus dorsal (horizontal ou incliné), étaitassocié à: durée réduite du second stade (10trials: moyenne 4.29 minutes, intervalle de



confiance à 95% 2.95 à 5.64 minutes) - ce résultatétait en grande partie du aux femmes assignées àutiliser un coussin d'accouchement; une petitediminution des accouchements instrumentaux (18trials: risque relatif 0.84, intervalle deconfiance à 0.95% 0.73 à 0.98); une diminution desépisiotomies (12 trials: RR 0.84, IC 95% 0.79 à0.91); une augmentation des déchirures du seconddegré (11 trials: RR 1.23, IC 95% 1.09 à 1.39); uneaugmentation des pertes sanguines supérieures à 500ml (11 trials: RR 1.68, IC 95% 1.32 à 2.15); moinsde douleurs sévères rapportées pendant le secondstade du travail (1 trial: RR 0.73, IC 95% 0.60 à0.90); moins d'anomalies du rythme cardiaque foetal(1 trial: RR 0.31, IC 95% 0.08 à 0.98).

CONCLUSIONS: Les analyses de cette revue suggèrentplusieurs bénéfices possibles des positionsverticales, alliés à la possibilité d'uneaugmentation du risque des pertes sanguinessupérieures à 500 ml. Les femmes devraient êtreencouragées à donner naissance dans la positionqu'elles trouvent la plus confortable. Jusqu'à ceque les bénéfices et risques des différentespositions d'accouchement aient pu être établis avecune plus grande certitude, par des trials deméthodologie robuste, les femmes devraient pouvoirfaire des choix éclairés sur les positionsd'accouchement qu'elles souhaiteraient utiliserpour la naissance de leurs bébés.

Gupta JK, Hofmeyr GJ. Position for women duringsecond stage of labour.Cochrane Database Syst Rev. 2004;(1):CD002006.

http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002006/frame.html

Aucune différencenotable des effetsd'une périduraleambulatoire parrapport à unepériduralehabituelle obligeanta rester couchée.

[1120] BACKGROUND: New techniques for administeringepidural analgesia allow increased mobility forlabouring women with epidurals. Aim: To determinethe effect of ambulation or upright positions inthe first stage of labour among women with epiduralanalgesia on mode of delivery and other maternaland infant outcomes.

METHODS: We undertook a systematic review and meta-analysis of randomised controlled trials (RCT) ofambulation or upright positions versus recumbencyin the first stage of labour among women witheffective first-stage epidural analgesia in anuncomplicated pregnancy. Trials were identified bysearching Medline, Embase and CINAHL databases andthe Cochrane Trials Register to March 2004. Trialeligibility and outcomes were prespecified. Grouptabular data were obtained for each trial andanalysed using meta-analytic techniques.

RESULTS: There were five eligible RCT, with a total



of 1161 women. There was no statisticallysignificant difference in the mode of delivery whenwomen with an epidural ambulated in the first stageof labour compared with those who remainedrecumbent: instrumental delivery (relative risk(RR) = 1.16, 95% confidence interval (CI) 0.93-1.44) and Caesarean section (RR = 0.91, 95% CI0.70-1.19). There were no significant differencesbetween the groups in use of oxytocin augmentation,the duration of labour, satisfaction with analgesiaor Apgar scores. There were no apparent adverseeffects of ambulation, but data were reported byonly a few trials.

CONCLUSIONS: Although ambulation in the first stageof labour for women with epidural analgesiaprovided no clear benefit to delivery outcomes orsatisfaction with analgesia, neither were there areany obvious harms.

Roberts CL, Algert CS, Olive E. Impact of first-stage ambulation on mode of delivery among womenwith epidural analgesia.Aust N Z J Obstet Gynaecol. 2004 Dec;44(6):489-94.


Les femmesoccidentales neconnaissent engénéral que laposition endécubitus dorsal,mais apprécient derecevoir del'information surd'autres positions,et d'êtreencouragées àprendre la positionqui leur convient.

[1121] The aim of this study was to gain insightinto the influences on women's use of birthingpositions, and into the labor experiences of womenin relation to the birthing positions they used.Quantitative studies have shown some medicaladvantages of non-supine birthing positions. Theyalso suggested some psychological benefits butthese are difficult to interpret. In this study in-depth interviews were conducted to gain a deeperunderstanding of the relationship between birthingpositions and the labor experience. We found thatthe advice given by midwives was the most importantfactor influencing the choice of birthingpositions. If medically possible, women benefitedfrom having the autonomy to find the positions thatwere most useful to them. Their choices variedgreatly, as did their experience of pain inrelation to the type of position. Women, regardlessof ethnicity, were most familiar with the supineposition but valued practical information on otheroptions. In conclusion, because the supine positionis dominant in westernized societies, midwives havean important role to play in widening the range ofwomen's choices. Midwives should empower women tofind the positions that are most suitable for them,by giving practical advice during pregnancy andlabor.

De Jonge A, Lagro-Janssen AL. Birthing positions. Aqualitative study into the views of women aboutvarious birthing positions.



J Psychosom Obstet Gynaecol. 2004 Mar;25(1):47-55.


Méta-analyse degrande qualitécomparantl'accouchement enposition supine àd'autres positions.Les seuls résultatsréellementsignificatifs sont :en position supine,plus d'extractionsinstrumentales etplus d'épisiotomies,plus de douleurressentie et moinsde satisfactionmaternelle. Aucunedes variablesfoetales ne montrede différencesignificative.

[1122] L'utilisation en routine de la positionlithotomique pendant la deuxième phase du travailpeut être considérée comme une intervention en soidans le déroulement physiologique del'accouchement. Le but de cette étude est d'établirsi il est justifié que cette pratique perdure. Neufétudes randomisées contrôlées, et une étude decohorte, ont été incluses. Une méta-analyse montrequ'il y a plus d'extractions instrumentales etd'épisiotomies en position lithotomique. Les pertesde sang et taux d'hémarrogie post-partum sont plusfaibles, mais il n'est pas certain que cettedifférence soit réelle ou due à la méthode demesure. Bien qu'hétérogènes, les données indiquentque les femmes ressentent plus de douleur sévère enposition lithotomique et qu'elles préfèrentd'autres positions pour accoucher.

Nous avons décelé beaucoup de problèmesméthodologiques dans ces études, et nous remettonsen question la pertinence des études randomiséescontrôlées pour l'étude de ce problème. Une étudede cohorte serait plus appropriée, associée à uneméthode qualitative pour étudier les expériencesdes femmes. Des mesures de laboratoire objectivesdevraient être utilisées pour examiner lesdifférences de perte sanguine.

En conclusion, les résultats ne justifient pas decontinuer à utiliser la position lithotomique enroutine pour le second stade du travail.

De Jonge A, Teunissen TA, Lagro-Janssen AL. Supineposition compared to other positions during thesecond stage of labor: a meta-analytic review.J Psychosom Obstet Gynaecol. 2004 Mar;25(1):35-45.


Remarques :Texte en acces libre

Aux sages-femmes,comment bienreconnaitre latransition, etaccompagner lesmoments intenses,physiques etémotionnels, lorsquela naissance devientimminente.

[1164] When labour moves from the phase ofdilatation to the phase of active maternal pushing,the whole tempo of activity changes. As the natureof her uterine activity changes, the mother’sresponse to her labour often moves throughconfusion and loss of control to intense physicaleffort and exertion as her baby is finally pushedtowards its birth. Both parents require stamina andcourage, and confidence in the skill of theattendant midwife. Excitement and expectation mountas the birth becomes imminent. A happy outcome willdepend upon mutual respect and trust between



professionals and parents. A mother will neverforget a midwife who positively supports hercapacity to give birth to her baby.the context ofthis debate, the chapter aims to:

• consider the nature of the transitional andsecond stage phases of labour• describe the usual sequence of events duringthese stages• summarise signs of transition and of theexpulsive phase of labour• discuss the care of the mother and her partner• review the observations that should be carriedout at this time.

Downe S. Transition and the second stage of labour:In: Henderson C & Cooper M (Eds) Myles Textbook forMidwives (14th edition) Harcourt Health Sciences,London. Chap.27:487-506.

http://www.intl.elsevierhealth.com/e-books/pdf/761.pdf

Régression de lapratique del’épisiotomie auCanada (67 à 38% sur11 ans)

[15] L’épisiotomie était jusqu’à présent unepratique habituelle, censée eviter les déchiruresdu perinée lors d’un accouchement. Toutefois depuisles années 80, plusieurs études ont démontré qu’iln’y a pas d’avantage et qu’il y a parfois desrisques accrus à effectuer une épisiotomiesystématique. Selon certaines études, une déchirureguérit mieux et provoque moins de souffrances aprèsla naissance qu’une coupure chirurgicale.

Un article dans Pre & Post Natal News rapporte quedes chercheurs du Civic Hospital d’Ottawa (Canada)ont étudié l’influence des recherches récentes surla pratique obstétrique. Ils ont établi qu’en 11ans, le taux annuel d’épisiotomies au Canada adiminué de 29% (66.8% en 1981/82 et 37.7% en1993/94). Ils en ont conclu que, en ce qui concernel’épisiotomie, la pratique médicale avait changéparallèlement aux résultats de recherche.

La Société des Gynécologues et Obstétriciens (SOGC)ne recommande pas actuellement l’épisiotomiesystématique. Elle indique que les facteurs quipermettent les muscles du périnée de se détendresont l’adoption de la position verticale, quipermet à la femme de pousser spontanément, uneseconde phase d’expulsion sans limite de temps, etune sortie de la tête lente. Dans certains cas,l’épisiotomie est utile, par exemple quand, lors del’utilisation de forceps, il est important de fairenaître le bébé rapidement.

Spicer, Susan. Episiotomy Rates are Dropping.Recent studies question necessity of routineepisiotomies



http://www.todaysparent.com/pregnancybirth/labour/article.jsp?content=1065

Etude randomiséecontrôlée, sur desfemmes en travailspontané oudéclenché. Le faitde marcher souspériduraleambulatoire a pourseul effet uneréduction notable dutemps du travail.

[238] OBJECTIVES: Ambulatory epidural analgesia hasbecome a common option for women in labor inFrance. We tested the hypothesis that a method ofepidural analgesia that allowed women to walk hadspecific advantages regarding mode of delivery,consumption of local anesthetic, oxytocinrequirement, and labor duration.

METHODS: Two hundred and twenty-one women withuncomplicated pregnancies who presented inspontaneous labor between 36 and 42 weeks ofgestation or who were scheduled for induced laborwere randomly divided into two groups, ambulatoryand non-ambulatory. All were given intermittentepidural injections of 0.1% ropivacaine with 0.6microg/ml sufentanil for analgesia during labor(P<0.05 was considered significant). None of thewomen had previous cesarean delivery.

RESULTS: There were no significant differencesbetween the two groups in mode of delivery,consumption of local anesthetic, or oxytocinrequirement. However, a significant difference wasnoted in labor duration (173.4+/-109.9 min vs.236.4+/-130.6 min; P=0.001).

CONCLUSIONS: Walking with ambulatory laboranalgesia shortens labor duration but has no othereffect on the progress and outcome of labor.

Karraz MA. Ambulatory epidural anesthesia and theduration of labor.International Journal of Gynecology & Obstetrics.2003 Feb;80(2):117-22.

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T7M-47S6Y70-4&_coverDate=02%2F28%2F2003&_alid=134818052&_rdoc=1&_fmt=&_orig=search&_qd=1&_cdi=5062&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=2328299&md5=9d7f21cce78b47162c12b8e424b1043d

Remarques :Mais les conditions si artificielles n'on guere dulaisse de spontaneite aux femmes. Le mélange entretravail spontané et declenché est un aussi un grospoint faible de cette étude.

Les primipares souspériduraleambulatoire peuventmaintenir uneposition verticalejusqu'à lanaissance, à

[1100] PURPOSE: To present research findings andrelated nursing implications from an observationalstudy designed to evaluate the use of uprightpositioning during second stage labor with patientswho had received low-dose epidural analgesia.

STUDY DESIGN AND METHODS: This descriptive study



condition d'êtresoutenuesphysiquement etémotionnellement enpermanence.

evaluated outcomes from a sample of 74 healthywomen having their first childbirth. They had allreceived epidural analgesia during the first andsecond stages of labor. Data were also collected bynurses on the use of birthing beds, and the extentof physical and emotional support the women neededwhile following the upright positioning studyprotocol.

RESULTS: All women were able to maintain uprightpositions throughout the second stage of laborfollowing epidural analgesia administration. Noadverse neonatal outcomes or maternal problems(such as excessive vaginal bleeding) weredocumented.

CLINICAL IMPLICATIONS: Although women were capableof assuming upright positions during second stage,the study results indicated that constant physicaland emotional support was necessary for most women.Future research on methods to prepare women formultiple position options after administration oflow-dose epidural analgesia should be undertaken.In addition, nurses should evaluate the benefits ofupright positioning in terms of facilitatingprogress of labor.

Mayberry LJ, Strange LB, Suplee PD, Gennaro S. Useof upright positioning with epidural analgesia:findings from an observational study.MCN Am J Matern Child Nurs. 2003 May-Jun;28(3):152-9.


Remarques :Parce que les femmes sous peri mais allongees n'ontbesoin d'aucunaccompagnement emotionnel ….

Moins de douleur enposition assise.

[1123] BACKGROUND: While the effect of the maternalposition on reducing labor pain has been studied,the data presented to date have not beenconclusive.

OBJECTIVES: To determine if maternal positionreduced the intensity of labor pain during cervicaldilatation from 6 to 8 centimeters.

METHOD: Pain intensity was measured using thevisual analogue scale (VAS) on 39 primiparous and19 multiparous women (N = 58) who alternatelyassumed the sitting and supine positions for 15minutes during cervical dilatation from 6 to 8centimeters.

RESULTS: The pain scores for the sitting positionwere significantly lower than those for the supine



position. The Wilcoxon signed-ranks test showed theVAS scores for the (a) total labor pain ("total"being defined as both abdominal and lumbar pain)during contraction (p =.011), (b) continuous totallabor pain (p =.001), (c) lumbar pain duringcontraction (p <.001), and (d) continuous lumbarpain (p <.001) in the sitting position(significantly lower than in supine position). Thediminished pain scores were greater than 13millimeters, which is the minimum clinicallysignificant change in patient pain severity asmeasured with the 100 millimeter VAS. The largestdecrease occurred in lower back pain. Nosignificant differences were found for abdominalpain scores in either the sitting or supinepositions.

CONCLUSION: The sitting position offers aneffective method to relieve lower back labor painduring cervical dilatation from 6 to 8 centimeters.Similar relief was experienced for women whoreported pain only on contraction as well as thosewith continuous pain.

Adachi K, Shimada M, Usui A. The relationshipbetween the parturient's positions and perceptionsof labor pain intensity.Nurs Res. 2003 Jan-Feb;52(1):47-51.


De plus en plusd'interventions sontpratiquées sanspreuve de leurefficacité, sous lapression du secteurprivé, du médico-légal, sansconsentementéclairé. Des tauxplus élevésd'accouchementnormaux seraientobtenus simplementen changeant lescroyances et enimplémentant lapratique de lamédecine factuelle.

[475] Summary points

- Obstetricians play an important role inpreserving lives when there are complications ofpregnancy or labour

- In developed countries, however, obstetricianinvolvement and medical interventions have becomeroutine in normal childbirth, without evidence ofeffectiveness

- Factors associated with increased obstetricintervention seem to include private practice,medicolegal pressures, and not involving womenfully in decision making

- Emerging evidence suggests that higher rates ofnormal births are linked to beliefs about birth,implementation of evidence based practice, and teamworking

Johanson R, Newburn M, Macfarlane A. Has themedicalisation of childbirth gone too far?The British Medical Journal 2002;324:892-895.

http://bmj.bmjjournals.com/cgi/content/full/324/7342/892?eaf



La position et letype d'accoucheur,obstétricien ousage-femme, ont uneinfluence sur l'étatdu périnée.

[1101] BACKGROUND: The literature is tentative inestablishing links between birth position andperineal outcome. Evidence is inconclusive aboutrisks and benefits of women's options for birthposition. The objective of this study was to gainfurther evidence to inform perinatal caregiversabout the effect of birth position on perinealoutcome, and to assist birth attendants inproviding women with information and opportunitiesfor minimizing perineal trauma.

METHODS: Data from 2891 normal vaginal births wereanalyzed. Descriptive statistics were obtained forvariables of interest, and cross-tabulations weregenerated to explore possible relationships betweenperineal outcomes, birth positions, and accoucheurtype. Logistic regression models were used toexamine potential confounding and interactioneffects of relevant variables.

RESULTS: Multiple regression analysis revealed astatistically significant association between birthposition and perineal outcome. Overall, the lateralposition was associated with the highest rate ofintact perineum (66.6%) and the most favorableperineal outcome profile. The squatting positionwas associated with the least favorable perinealoutcomes (intact rate 42%), especially forprimiparas. A statistically significant associationwas demonstrated between perineal outcome andaccoucheur type. The obstetrician group generatedan episiotomy rate of 26 percent, which was morethan five times higher than episiotomy rates forall midwife categories. The rate for tear requiringsuture of 42.1 percent for the obstetric categorywas 5 to 7 percentage points higher than that formidwives. Intact perineum was achieved for 31.9percent of women delivered by obstetricianscompared with 56 to 61 percent for three midwiferycategories.

CONCLUSION: Findings contribute to growing evidencethat birth position may affect perineal outcome.Women's childbirth experiences should reflectdecisions made in partnership with midwives andobstetricians who are equipped with knowledge ofrisks and benefits of birthing options and skillsto implement women's choices for birth. Furtheridentification and recognition of the strategiesused by midwives to achieve favorable perinealoutcomes is warranted.

Shorten A, Donsante J, Shorten B. Birth position,accoucheur, and perineal outcomes: informing womenabout choices for vaginal birth.Birth. 2002 Mar;29(1):18-27.

http://www.blackwell-



synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=0730-7659&date=2002&volume=29&issue=1&spage=18

Les femmes pauvresde la région desChiapas préfèrent unaccouchementtraditionel qui leurdonne le choix dulieu, de la positiond'accouchement, dela présence de leursproches.

[1102] This study was designed to better understandhow women in a developing region choose between themultiple options available to them for birthing. Weconducted focused, open-ended ethnographicinterviews with 38 nonindigenous, economicallymarginal women in Chiapas, Mexico. We found thatalthough medical services for birthing were readilyavailable to them, these women most often chosetraditional birth attendants (TBAs) for assistancewith their births. They expressed a clearpreference for TBAs in the case of a normal birth,but viewed medical services as useful fordiagnosing and managing problem deliveries and fortubal ligations. They favored TBAs because theyvalued being able to choose birthing locations andbirthing positions and to have relatives presentduring the birth, all features they must give upfor medically attended births in this region.

Hunt LM, Glantz NM, Halperin DC. Childbirth care-seeking behavior in Chiapas.Health Care Women Int. 2002 Jan;23(1):98-118.


Revue des facteursobstétriquesoptimaux pendant lesecond stade, enparticulier lespositions de lafemme et le réflexede poussée.Réflexion sur cesfacteurs en cas depéridurale.

[1124] Recognition that the available evidence doesnot support arbitrary time limits for the secondstage of labor has led to reconsideration of theinfluence of maternal bearing down efforts onfetal/newborn status as well as on maternal pelvicstructural integrity. The evidence that theduration of 'active' pushing is associated withfetal acidosis and denervation injury to maternalperineal musculature has contributed to thedelineation of at least two phases during secondstage, an early phase of continued fetal descent,and a phase of "active" pushing. The basis for therecommendation that the early phase of passivedescent be prolonged and the phase of activepushing shortened by strategies to achieveeffective, but non-detrimental pushing efforts isreviewed. The rational includes an emphasis on theobstetric factors that are optimal for birth andconducive to efficient maternal bearing down.Explicit assessment of these obstetric factors andobservation of maternal behavior, particularlyevidence of an involuntary urge to push, should becoupled with the use of maternal positions thatwill promote fetal descent as well as reducematernal pain. The use of epidural analgesia forpain relief can also be accompanied by these sameprinciples, although further research is needed toverify the strategies of "delayed pushing" andmaintenance of pain relief along with areconceptualization of the second stage of labor.



Roberts JE. The "push" for evidence: management ofthe second stage.J Midwifery Womens Health. 2002 Jan-Feb;47(1):2-15.


Les femmes souspériduraleambulatoire enprofitenteffectivement pourbouger et ont uneseconde phase dutravail plus courte.

[1220] Neuraxial blockade is widely used for painrelief in labour. This form of analgesia may beassociated with an increase in instrumentaldelivery rates due to dystocia. 'Traditional'epidurals cause motor blockade and henceimmobility. Using a low dose anaesthetic-opioidcombination with either epidural or combinedspinal-epidural, selective sensory blockade can beachieved, allowing mobility as well as pain relief.In this study, we randomised women with combinedspinal-epidural analgesia either to mobilise(upright group n=25) or to remain recumbent (n=41)in the second stage of labour. We found women inthe upright group had significantly shorter totalsecond stage, (132 vs 109 min,P =0.019)particularly during the pushing phase (73 vs 51min, P=0.011) Although there were fewerinstrumental deliveries in the upright group, thiswas not statistically significant. Women who wererandomised to the upright group, did actuallymobilise. We conclude that mobilisation in thesecond stage of labour is possible, and may reducethe length of the second stage.

Golara M, Plaat F, Shennan AH. Upright versusrecumbent position in the second stage of labour inwomen with combined spinal-epidural analgesia.Int J Obstet Anesth. 2002 Jan;11(1):19-22.


La périduraleambulatoire neraccourcit pas ladurée entre la posede la péridurale etla dilatationcomplète.

[1089] Background: Ambulatory epidural analgesia(AEA) is a popular choice for labor analgesiabecause ambulation reportedly increases maternalcomfort, increases the intensity of uterinecontractions, avoids inferior vena cavacompression, facilitates fetal head descent, andrelaxes the pelvic musculature, all of which canshorten labor. However, the preponderance ofevidence suggests that ambulation during labor isnot associated with these benefits. The purpose ofthis study is to determine whether ambulation withAEA decreases labor duration from the time ofepidural insertion to complete cervical dilatation.

Methods: In this prospective, randomized study, 160nulliparous women with AEA were randomly assignedto one of two groups: AEA with ambulation and AEAwithout ambulation. AEA blocks were initiated with15-20 ml ropivacaine (0-07%) plus 100 mug fentanyl,followed by a continuous infusion of 0.07%ropivacaine plus 2 mug/ml fentanyl at 15-20 ml/h.



Maternal measured variables included ambulationtime, time from epidural insertion to completedilatation, stage Il duration, pain Visual AnalogueScale scores, and mode of delivery. APGAR scoreswere recorded at 1 and 5 min.

Results are expressed as mean +/- SD or niedian andanalyzed using the t test, chi-square, or the Mann-Whitney test at P less than or equal to 0.05.

Results: The ambulatory group walked 25.0 +/- 23.3min, sat upright 40.3 +/- 29.7 min, or both. Timefrom epidural insertion to complete dilatation was240.9 +/- 146.1 min in the ambulatory group and211.9 +/- 133.9 min in the nonambulatory group (P0.206).

Conclusion: Ambulatory epidural analgesia withwalking or sitting does not shorten labor durationfrom the time of epidural insertion to completecervical dilatation.

Vallejo MC, Firestone LL, Mandell GL, Jaime F,Makishima S, Ramanathan S. Effect of epiduralanalgesia with ambulation on labor durationANESTHESIOLOGY 95 (4): 857-861 OCT 2001

www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve& db=PubMed&list_uids=11605924&dopt=Abstract

La position assiseou couché sur leventre est favorablepour l'oxigénationfoetale comparéeavec la positionallongée sur le dos.

[1095] Abstract: Background: The evaluation of thebirth position and its effects on maternal andfetal wellbeing has been a topic of perinatalresearch over the last decades. The aim of ourobservational study was to determine the effects ofa modified and vertical maternal position on fetaloxygen saturation measured by pulse oximetry.

Methods: Fetal oxygen saturation was measured bypulse oximetry in 56 labouring women randomly andsuccessively adopting the supine position in 96.4%,the sitting position in 25.0%, the standingposition in 14.3% and the prone position in 12.5%.The statistical analysis addressed the integrated10 minutes period of SpO(2) registrations beforeversus after adopting the modified position,Furthermore the mean values and the standarddeviation (SD) for the total registration periodsof different birth position was calculated.

Results: While the supine position induced areduction in oxygen saturation, sitting and proneposition were favorable for fetal oxygenation ascompared to horizontal position.

Discussion: These findings implicate a clinicalbenefit of the modified birth position.

Schmidt S, Sierra F, Hess C, Neubauer S, Kuhnert M,



Heller G. Effects of a modified maternal positionduring labour on fetal oxygenation measured bypulse oximetryZEITSCHRIFT FUR GEBURTSHILFE UND NEONATOLOGIE 205(2): 49-53 MAR-APR 2001

Une positionacrobatique (lesgenoux jusqu'auxoreilles, allongéesur la table) pouraugmenterl'efficacité descontractions. Lesmêmes auteurs sefont les avocats del'expressionabdominale"calibrée".

[1224] McRoberts' position is used during thesecond stage of labour to facilitate delivery ofthe fetal shoulders. Few clinical studies have beendone to measure its efficacy. We measuredintrauterine pressure in 22 women in term labour,after the vertex reached 3+ station, in the dorsallithotomy position. Patients pushed with legseither in stirrups or hyperflexed by 1358(McRoberts' position). Maternal valsalvatransiently increased the expulsive force by 32%over naturally occurring contractions. Use ofMcRoberts' position almost doubled the intrauterinepressure developed by contractions alone (from 1653mm Hg s to 3262 mm Hg s [97%]).

Buhimschi CS, Buhimschi IA, Malinow A, Weiner CP.Use of McRoberts' position during delivery andincrease in pushing efficiency.Lancet. 2001 Aug 11;358(9280):470-1.

Revue des articlessur la positionmaternelle pendantle travail.

[1125] The position adopted naturally by womenduring birth has been described as early as 1882 byEngelmann. He observed that primitive woman, notinfluenced by Western conventions would try toavoid the dorsal position and was allowed to changeposition as and when she wished. Different uprightpositions could be achieved using posts, slunghammock, furniture, holding on to a rope, knottedpiece of cloth, or the woman could kneel, crouch,or squat using bricks, stones, a pile of sand, or abirth stool. Today the majority of women in Westernsocieties deliver in a dorsal, semi-recumbent orlithotomy position. It is claimed that the dorsalposition enables the midwife/obstetrician tomonitor the fetus better and thus to ensure a safebirth.This paper examines the historical backgroundof the different positions used and its evolutionthroughout the decades. We have reviewed theavailable evidence about the effectiveness,benefits and possible disadvantages for the use ofdifferent positions during the first and secondstage of labour.

Gupta JK, Nikodem C. Maternal posture in labour.Review.Eur J Obstet Gynecol Reprod Biol. 2000Oct;92(2):273-7.


Les présentationslatérales oupostérieures dufoetus ont plus de

[1196] BACKGROUND: Lateral and posterior positionof the fetal presenting parts may be associatedwith more painful, prolonged or obstructed labourand difficult delivery. It is possible that



chance de serésoudre rapidementsi la mère est enposition “à quatrepattes” que si elleest allongée sur ledos ou sur le côté.

maternal posture may influence fetal position.

OBJECTIVES: The objective of this review is toassess the effects of adopting a hands and kneesmaternal posture in late pregnancy when thepresenting part of the fetus is in a lateral orposterior position.

SEARCH STRATEGY: We searched the Cochrane Pregnancyand Childbirth Group trials register and theCochrane Controlled Trials Register. Date of lastsearch: February 1999.

SELECTION CRITERIA: Randomised trials of hands andknees maternal posture compared to other postures.DATA COLLECTION AND ANALYSIS: Both reviewersassessed trial eligibility and quality.

MAIN RESULTS: One trial involving 100 women wasincluded. Four different postures (four groups of20 women) were combined for the comparison with thecontrol group of 20 women. Lateral or posteriorposition of the presenting part of the fetus wasless likely to persist following 10 minutes in thehands and knees position compared to a sittingposition (relative risk 0.25, 95% confidenceinterval 0.17 to 0.37).

REVIEWER'S CONCLUSIONS: Hands and knees maternalposture for lateral or posterior fetal presentationappears to result in short term effects on fetalposition. No other perinatal or maternal outcomeswere reported. There is not enough evidence toevaluate the effectiveness of a hands and kneesmaternal posture when the fetal presenting part islateral or posterior, on clinically importantoutcomes.

Hofmeyr GJ, Kulier R. Hands/knees posture in latepregnancy or labour for fetal malposition (lateralor posterior).Cochrane Database Syst Rev. 2000;(2):CD001063.


Les femmes devraientêtre incitées àaccoucher dans laposition qui leurparaît la plusconfortable. (Revuesystématique de labase de donnéesCochrane)

[1206] BACKGROUND: For centuries, there has beencontroversy around whether being upright (sitting,birthing stools, chairs, squatting) or lying downhave advantages for women delivering their babies.OBJECTIVES: The objective of this review was toassess the benefits and risks of the use ofdifferent positions during the second stage oflabour (i. e. from full dilatation of the cervix).

SEARCH STRATEGY: Relevant trials are identifiedfrom the register of trials maintained by theCochrane Pregnancy and Childbirth Group, and fromthe Cochrane Controlled Trials Register.



SELECTION CRITERIA: Trials were included whichcompared various positions assumed by pregnantwomen during the second stage of labour. Randomisedand quasi-randomised trials with appropriatefollow-up were included.

DATA COLLECTION AND ANALYSIS: Trials wereindependently assessed for inclusion, and dataextracted, by the two authors. Disagreements wouldhave been resolved by consensus with an editor.Meta-analysis of data is performed using the RevMansoftware.

MAIN RESULTS: Results should be interpreted withcaution as the methodological quality of the 18trials was variable. Use of any upright or lateralposition, compared with supine or lithotomypositions, was associated with: 1. Reduced durationof second stage of labour (12 trials - mean 5.4minutes, 95% confidence interval (CI) 3.9 - 6.9minutes). This was largely due to a considerablereduction in women allocated to use of the birthcushion. 2. A small reduction in assisteddeliveries (17 trials - odds ratio (OR) 0.82, 95%CI 0.69 - 0.98). 3. A reduction in episiotomies (11trials - OR 0.73, 95% CI 0.64 - 0.84). 4. A smallerincrease in second degree perineal tears (10 trials- OR 1.30, 95% CI 1.09 - 1.54). 5. Increasedestimated risk of blood loss > 500ml (10 trials -OR 1.76, 95% CI 1.34 - 3.32). 6. Reduced reportingof severe pain during second stage of labour (1trial - OR 0.59, 95% CI 0.41 - 0.83). 7. Fewerabnormal fetal heart rate patterns (1 trial - OR0.31, 95% CI 0.11 - 0.91).

REVIEWER'S CONCLUSIONS: The tentative findings ofthis review suggest several possible benefits forupright posture, with the possibility of increasedrisk of blood loss > 500ml. Women should beencouraged to give birth in the position they findmost comfortable. Until such time the benefits andrisks of various delivery positions are estimatedwith greater certainty when methodologicallystringent trials data are available, then womenshould be allowed to make informed choices aboutthe birth positions in which they might wish toassume for delivery of their babies.

Gupta JK, Nikodem VC. Woman's position duringsecond stage of labour.Cochrane Database Syst Rev. 2000;(2):CD002006.


Accoucher enposition verticaleest aussi sûr qu'en

[1103] The objective of the study was to assesswhether vertical positions during childbirth are assafe as horizontal positions. In the course of



positionhorizontale.

delivery the authors observed 328 women with normalpregnancies, matched for parity and age, dividedinto two groups by type of delivery. They comparedthe course of the delivery, length of stages I andII, birth injuries, haemorrhage of the mother(number of episiotomies and grade III rpt. andblood losses) and the condition of the infant afterdelivery (Apgar score during the fifth and tenthminute, pH of the umbilical artery). Thedifferences were evaluated by the chi square testand were not statistically significant. In thevertical position no greater risk was found formother or infant and it can be considered equallysafe as the horizontal one but it is more apt formother and foetus.

Podalova S, Hohlova S, Maly Z. [Comparison ofsafety of the vertical and horizontal position fordelivery].Ceska Gynekol. 1999 Apr;64(2):100-2.


Remarques :Article en langue tchèque

Etude randomiséecontrôlée comparantl'accouchement enposition accroupieet dans la positionobstétricaleclassique. Aucunedifférencesignificative dansles variables prisesen compte, sauf lasatisfaction desfemmes en couchedans la positionaccroupie.

[1184] Objectif de l'étude. Évaluer l'influenced'une position d'accouchement verticale, laposition accroupie, sur la phase d'expulsion, enétudiant différents paramètres que sont la duréed'expulsion, l'état néonatal, le moded'accouchement, la survenue d'hémorragie de ladélivrance, l'état périnéal et enfin le confort desparturientes.

Type d'étude. Randomisée, monocentrique,comparative, ouverte, prospective.

Matériel et méthode. Après réalisation d'une étudede faisabilité de manière rétrospective, 240patientes ont été incluses dans 2 groupes danslesquels l'accouchement était réalisé soit enposition accroupie soit en position classique. Tousles paramètres exposés ci∆dessus ont été recueilliset traités par le logiciel Epi∆Info, en utilisantles tests t de Student, du χ2, deKruskall∆Wallis.

Résultats. Notre étude a montré une tendance à ladiminution de la durée d'expulsion ainsi qu'à ladiminution des extractions instrumentales dans legroupe " position accroupie ", sans toutefoisatteindre le seuil de significativité. L'étatnéonatal n'était pas modifié. Le nombred'hémorragies de la délivrance et le nombre dedéchirures périnéales accusaient une tendance àl'augmentation, sans atteindre le seuil designificativité. Enfin, la satisfaction des



parturientes ayant accouché en position accroupieétait très forte.

Conclusion. L'essai comparatif réalisé ne permetpas de valider de façon certaine les avantagesthéoriques de l'accouchement en position accroupie.Ces données semblent conformes aux résultats desessais déjà effectués publiés dans la littérature.On soulignera enfin que si elle ne démontre pasd'avantage médical sur les paramètres étudiés, laposition accroupie n'est pas délétère, et peutapporter un plus grand confort aux parturientes quidésirent l'appliquer.

Racinet C, Eymery P, Philibert L, Lucas C. [Laborin the squatting position. [A randomized trialcomparing the squatting position with the classicalposition for the expulsion phase] [En français].J Gynecol Obstet Biol Reprod (Paris). 1999Jun;28(3):263-70.

http://www.e2med.com/index.cfm?fuseaction=viewArtDossier&DartIdx=66602&DIssIdx=4492&DChapIdx=32525

Remarques :Texte en accès libre.[438] The authors are the first in Hungary to haveapplied the method of vertical delivery with thehusband's or partner's presence in the deliveryroom. This is part of the authors' family-centereddelivery program at the Maternity Ward of Borsod-Abauj-Zemplen County Hospital, Miskolc. Acomparison of 321 births was carried out, whichincluded 158 vertical deliveries and 163 horizontaldeliveries. During both vertical and horizontaldeliveries, the husband or partner was present inthe delivery room. The comparison included themother's biometrics and social characteristics, aswell as the circumstances of the delivery and theclinical parameters of the newborns. Certain stagesof delivery in the vertical position took a shorterperiod of time compared to horizontal delivery, butthe differences were not significant. Episiotomieswere carried out in fewer cases of verticaldeliveries, and significant injuries due to thelack of an episiotomy in the case of verticaldeliveries were not detected. The parameterscharacterizing the clinical state of the newbornswere the same in both groups. The answers given toquestionnaires supported the favorablepsychological effects of a vertical delivery. Theauthors hope that vertical delivery, as a possiblealternative, will find its place in obstetricpractice in Hungary.

Hagymasy L, Gaal J. A comparative study of verticaland horizontal deliveries in the presence and withthe assistance of the woman's partner.



J Psychosom Obstet Gynaecol. 1998 Jun;19(2):98-103.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9638602&dopt=Abstract

La liberté deposition devraitêtre respectée chezles parturientes, etla pratique del’épisiotomie nedevrait plus êtresystématique.

[439] OBJECTIVE: Evaluate possible advantages ordisadvantages of the sitting over the horizontalposition during the second stage of labor.

DESIGN AND METHODS: Clinical trial randomlyselecting 127 volunteers for the sitting positionand 121 for the horizontal position during thesecond stage of labor. Duration of the second stageand of expulsion of the placenta, vulvo vaginal andperineal lacerations, blood lost and Apgar scorewere evaluated.

RESULTS: There was a non-significant decrease of3.4 min in the duration of the second period in thevertical position in comparison with the horizontalposition. There was a similar difference in theduration of delivery of the placenta, but also non-significant. Blood loss was slightly greater amongwomen delivering in vertical position, but thedifference did not reach significance.Breastfeeding did not show any influence on bloodloss and on the time for delivering the placenta.The incidence of perineal trauma was 44.1% forvertical position and 47% for horizontal positionin the whole group and of 47.8% and 71.2% in thegroup with history of episiotomy. This lastdifference was statistically significant. Theresults of this study are in the line of otherstudies that suggest some advantages and possibledisadvantages of the vertical position.

CONCLUSIONS: Mothers should be given the choice ofthe posture to be assumed during parturition. Thesupine position should not be imposed andepisiotomy should not be a routine.

Bomfim-Hyppolito S. Influence of the position ofthe mother at delivery over some maternal andneonatal outcomes.Int J Gynaecol Obstet. 1998 Dec;63 Suppl 1:S67-73.


Accouchement àdomicile : plus depérinées intacts.Noter aussil’influence négativedu massage périnéal.

[709] CONTEXTE: Les déchirures périnéales sont unesource importante de désagréments pour beaucoup defemmes. Dans cette étude descriptive, nousexaminons l'état du périnée dans une population defemmes ayant accouché à domicile, et donnons unedescription préliminaire des facteurs associés auxdéchirures périnéales et à l'épisiotomie.

METHODES: Etude de cohorte prospective de 1404accouchements à domicile planifiés.Les analyses sont concentrées sur 1068 femmes ayant



accouché à domicile avec une sage-femme, et 28cabinets de sages-femmes. Les traumatismespérinéaux incluent l'épisiotomie et les déchirures.Les écorchures mineures et déchiruressuperficielles qui n'ont pas nécessité de suturesont incluses dans le groupe des périnées intacts.Les liens entre les traumatismes périnéaux et lesvariables de l'étude ont été examinés globalement,et séparément pour les femmes multipares etprimipares.

RESULTATS: Dans cet échantillon, 69.6% des femmesavaient un périné intact, 15 (1.4%) ont eu uneépisiotomie, 28.9% avaient une déchirure du premierou deuxième degré, et 7 femmes (0.7%) desdéchirures du troisième ou quatrième degré. Desanalyses basées sur des régressions logistiquesmontrent que les périnées intacts sont associés àla multiparité, à un niveau socio-économiquefaible, et à une parité élevée, alors que lestraumatismes périnéaux sont associés à un âgeavancé (> ou = à 40 ans), à une épisiotomieprécédente, à un gain de poids de plus de 9 kilos,à un second stade du travail prolongé, et àl'utilisation d'huiles ou de lubrifiants. Parmi lesprimipares, les périnés intacts sont associés à unniveau socio-économique faible, à une positiond'accouchement à genoux ou à quatre pattes, et à unmaintien manuel du périnée, alors que lestraumatismes du périné sont associés aux massagesde celui-ci pendant l'accouchement.

CONCLUSIONS: Ces résultats suggèrent qu'il estpossible que les sages-femmes parviennent à obtenirun taux élevé de périnées intacts dans un lieuchoisi et avec une population sélectionnée.

Aikins Murphy P, Feinland JB. Perineal outcomes ina home birth setting.Birth. 1998 Dec;25(4):226-34.

http://www.blackwell-synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=0730-7659&date=1998&volume=25&issue=4&spage=226

Il paraît possiblede conseillerlargement lespositions verticaleslors de l'expulsion,tout en étantvigilant sur lerisque hémorragique.

[908] 1. La médicalisation de l'accouchement s'estaccompagnée de l'adoption de la positionhorizontale lors de l'expulsion foetale. Il paraîtutile de s'interroger sur la mécanique obstétricaleentraînée par cette position maternelle et sesconséquences maternelle et foetale. D'autrespositions existent qui semblent améliorer laqualité subjective de l'expulsion.

2. Les diverses positions se classent en :

- Positions verticales (assise, accroupie, deboutet agenouillée) ;- Positions horizontales (lithotomie, décubitus



latéral, position ventrale).

3. Conséquences anatomo-physiologiques despositions

- La position horizontale associe différentescomposantes qui expliquent un manque de confort etune progression plus lente du travail ;- La compression aorto-cave peut égalementfavoriser la souffrance foetale et l'hémorragie perpartum ;- Parmi les positions verticales, la positionaccroupie favorise au mieux la progression foetale.

4. L'analyse de la littérature récente (méta-analyses de Venditelli) recense 19 essaisrandomisés comparant position horizontale et autrespositions. Elle montre un taux plus faible desouffrances foetales, de dépressions néo-natales,de déchirures du périnée, une tendance à la baissedes extractions instrumentales, mais une tendance àl'augmentation des hémorragies de la délivrance.

Il paraît possible de conseiller largement lespositions verticales lors de l'expulsion, tout enétant vigilant sur le risque hémorragique.

C. Lucas, C. Racinet. Positions maternelles pourl’accouchement. Mises à jour en gynécologieobstétrique, tome XXII, p.331.

http://www.cngof.asso.fr/D_PAGES/PUMA_98.HTMLe fait de marchern'est ni positif ninégatif sur letravail. Il n'estpas dangereux nipour la mère ni pourleurs enfants.

[1090] Lack of effect of walking on labor anddelivery.

Bloom SL, McIntire DD, Kelly MA, Beimer HL, BurpoRH, Garcia MA, Leveno KJ. Lack of effect of walkingon labor and delivery.N Engl J Med. 1998 Jul 9;339(2):117-8.

L’utilisation depositions autre quelithtomique est unmoyen non-technologiqued’accentuer leprocessus normal del’accouchement.

[1126] This, the second of a two-part article,describes the findings of a national survey ofpracticing certified nurse-midwives (CNMs)regarding factors that affect the use of eightsecond-stage maternal positions. Lower CNM self-reported autonomy scores were associated with theuse of the lithotomy and dorsal supine positions;maternal preference and higher CNM self-reportedautonomy scores were associated with the use of thenonlithotomy positions. The use of nonlithotomypositions is one nontechnologic way to enhance thenormal process of birth.

Hanson L. Second-stage positioning in nurse-midwifery practices. Part 2: Factors affecting use.J Nurse Midwifery. 1998 Sep-Oct;43(5):326-30.



http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9803710[1152] A national survey of 800 certified nurse-midwives (CNMs) in active clinical practice wasconducted from April through June 1994. The purposeof the survey was to study the extent to whicheight operationally defined positions were used byCNM-attended women during the second stage of laborand factors that affected their use. This, thefirst of a two-part article, describes thepositions used as well as the CNMs' preferences forthe eight second-stage positions. The mostfrequently used second-stage position was sitting;the lithotomy position was rarely used by the CNMs.The survey findings reflect the preferences ofbirthing women.

Hanson L. Second-stage positioning in nurse-midwifery practices. Part 1: Position use andpreferences.J Nurse Midwifery. 1998 Sep-Oct;43(5):320-5.

Etude rétrospectivesur la roue Roma. Laphase 2 du travailest nettement pluscourte, le recoursaux antalgiques plusfaibles, lespérinées intactsplus fréquents, sansincidence sur lasécurité de la mèreet des bébés.

[1186] OBJECTIVE: To test the safety andpracticability of spontaneous deliveries with theRoma birthing wheel (RBW).

METHOD: The results of 1 year's clinical experience(1.12.1995-30.11.1996) with the RBW at theDepartment of Obstetrics and Gynecology,Wilhelminenspital, Vienna, were compared with theresults of a group of head-first deliveries beforeprocuring the RBW.

RESULTS: Out of 1,555 births, 1,377 (89%) werespontaneous; 209 (15%) women used the RBW. Comparedwith the figures before the RBW was available, thetotal duration of labor was reduced by about onethird; the birth canal was intact in 44% and theuse of painkillers reduced by a range between 8 and27%.

CONCLUSIONS: In spontaneous births the use of theRBW definitely has advantages, e.g., shortening ofthe procedure and acceptance on the part of thewomen; also, safety for both mother and childremains unchanged.

Rohrbacher A, Salzer H. [The Roma birthing wheel: 1year clinical experience in a specialty hospital][Article in German].Gynakol Geburtshilfliche Rundsch. 1998;38(3):158-63.


La liberté deposition et lemassage périnéal

[733] OBJECTIVE: To learn which factors influencingperineal integrity were modifiable by physiciansand pregnant women.



pendant le 3etrimestrecontribuent àl’accouchement avecun périnée intact.

DATA SOURCES: Medical, nursing, and midwiferyliterature was searched mainly for randomizedcontrolled trials.

STUDY SELECTION: We chose articles on perinealtrauma pattern, sexual dysfunction or satisfaction,urinary incontinence, and pelvic floor function. Weidentified 80 papers and studied 16 in detail.

SYNTHESIS: Five factors affected perinealintegrity: episiotomy, third-trimester perinealmassage, mother's position in second-stage labour,method of pushing, and administration of epiduralanalgesia. Episiotomy does not improve perinealoutcomes when used routinely. Third-trimesterperineal massage was discussed only in inadequatestudies. Studies comparing position in birth chairsand recumbent versus upright positions wereinadequate for making firm recommendations. Studiesof methods of pushing and use of epidural analgesiawere limited and uncontrolled; no recommendationswere possible.

CONCLUSION: Only limiting episiotomy can bestrongly recommended. In the absence of strong datato the contrary, women should be encouraged toengage in perineal massage if they wish and toadopt the birth positions of their choice.Caretakers should be aware of the possibility ofinterfering with placental function when women holdtheir breath for a long time when pushing.

Flynn P, Franiek J, Janssen P, Hannah WJ, Klein MC.How can second-stage management prevent perinealtrauma? Critical review.Can Fam Physician. 1997 Jan;43:73-84.


Les femmes quipouvaient bougerlors du travail ontsubi la moitié moinsd’extractionsassistées.

[1088] An abbreviated version of the Nurse-Midwifery Clinical Data Set was used to gather dataon all women (n = 3,049) who began intrapartum carewith a nurse-midwife in three sites.

Demographic information, intrapartum care, andoutcomes were recorded. The association ofambulation in labor with operative delivery wasexamined in a low-risk sample (n = 1,678) of womenwho did not receive care measures (epiduralanesthesia, oxytocin induction or augmentation)that preclude mobility in labor.

Women who ambulated for a significant amount oftime during labor (compared with those who did notambulate) had half the rate of operative delivery(2.7% vs. 5.5%).



Albers LL, Anderson D, Cragin L, Daniels SM, HunterC, Sedler KD, Teaf D. The relationship ofambulation in labor to operative deliverySource: JOURNAL OF NURSE-MIDWIFERY 42 (1): 4-8 JAN-FEB 1997


La majorité despatientes ontressenti moins dedouleurs abdominaleset lombaires enposition verticale.

[1091] This study was designed to evaluate therelationship between the parturient's position andher abdominal and lumbar (continuous andcontraction) pain during the first stage of labor.

A homogenous group of 100 parturients was randomlyassigned to alternately assume the horizontal orthe vertical position for 15-min periods. Theirpain was measured at 2-3, 4-5, 6-7, and 8-9centimeters dilatation. To avoid ''carry over''effect, these positions were preceded by a self-elected posture. Thus, the patient adopted (a) aself-elected position, (b) recumbent (or erect),(c) a self-elected position, (d) erect (orrecumbent), and so on. Pain intensity was measuredby the Argentine Pain Questionnaire's Present PainIntensity and the Huskisson's visual analoguescale. Only the patients with at least one painevaluation in both positions using both instrumentswere included in the study. The setting for thestudy was the obstetric department of a generalhospital for people connected with public education(professors, teachers, or members of schooladministrative staffs).

The analysis revealed that a majority of patientsfelt less abdominal and lumbar pain, eithercontinuous or due to contractions, duringrecumbency. The effect was more remarkable whendilation exceeded 5 centimeters and less intenseduring the first half of the first stage of labor.

Molina FJ, Sola PA, Lopez E, Pires C. Pain in thefirst stage of labor: Relationship with thepatient's positionJOURNAL OF PAIN AND SYMPTOM MANAGEMENT 13 (2): 98-103 FEB 1997


Les avantages dutravail en positiondebout sontprésentés. Lesaspects historiques,physiologiques andpsychosociaux sontdiscutés.

[1116] The advantages of an upright position duringlabor are presented, with historic, physiologic,and psychosocial aspects discussed. The influencesof modern obstetric practices such as electronicfetal monitoring and anesthesia practices arediscussed with findings related to the use ofupright positions from the Association of Women'sHealth, Obstetric, and Neonatal Nursing NationalResearch Utilization Project on Second Stage LaborManagement integrated. Recommendations for



facilitating upright positions on the labor anddelivery unit are presented.

R. H. Shermer and D. A. Raines. Positioning duringthe second stage of labor: moving back to basics.Journal of Obstetric, Gynecologic, and NeonatalNursing, Vol 26, Issue 6 727-734

http://jognn.awhonn.org/cgi/content/abstract/26/6/727

Le choix de laposture devrait êtreencouragé dans lesaccouchements àfaible risque.

[1127] OBJECTIVE: To assess the maternal andneonatal effects of upright compared with recumbentpositions during delivery, in terms of definedoutcome variables.

DESIGN: A randomised controlled trial.

SETTING: St Monica's Nursing Home, a midwife basedmaternity unit in Cape Town, South Africa.

PARTICIPANTS: Five hundred and seventeen women oflow obstetrical risk assigned to deliver at thenursing home.

RESULTS: The trial showed that women who adoptedthe upright posture for delivery experienced lesspain. perineal trauma and fewer episiotomies thanthose who delivered in the supine position.

CONCLUSION: The data suggest that in women of lowobstetrical risk, choice of posture during deliverymay be encouraged.

de Jong PR, Johanson RB, Baxen P, Adrians VD, vander Westhuisen S, Jones PW. Randomised trialcomparing the upright and supine positions for thesecond stage of labour.Br J Obstet Gynaecol. 1997 May;104(5):567-71.


La positionmaternelle couchéependant le travailest associée à unesaturation foetaleen oxygène plusfabile que laposition latéralegauche.

[1092] Objective: To determine the effects ofmaternal left lateral, right lateral, and supinepositions during labor on fetal oxygen saturationmeasured by pulse oximetry.

Methods: Fetal oxygen saturation measured by pulseoximetry was obtained in 15 laboring women randomlyand successively adopting left lateral, supine, andright lateral positions for 10 minutes each.Repeated measures analysis of variance was used forstatistical analysis.

Results: Changes in fetal oxygen saturation wereobserved in different maternal positions. Thesupine position was associated with a lower fetaloxygen saturation than the left lateral position.One supine hypotensive syndrome occurred and was



associated with a drop in fetal oxygen saturation.

Conclusion: Maternal supine position during laboris associated with a lower fetal oxygen saturationthan the left lateral position.

Carbonne B, Benachi A, Leveque ML, Cabrol D,Papiernik E. Maternal position during labor:Effects on fetal oxygen saturation measured bypulse oximetry.OBSTETRICS AND GYNECOLOGY 88 (5): 797-800 NOV 1996


Moins de déchirurespérinéales etd'épisiotomies enutilisant lespositions verticalesdans cette étuderetrospective. Pasd'influence sur lasanté du nouveau-né.

[1130] The maternal birthing position is not onlyinfluenced by physical factors but also culturecivilization. Nowadays more women prefer to givebirth in an upright position (sit, squat, kneel)which is highly supported by some familypractitioners. In this retrospective investigationwe compared 3 different groups of maternal birthingpositions (upright, lateral, mixed birthingposition i.e. mainly on the back) concerning thefetal outcome and maternal perineal injury. Therewas no difference in the APGAR-values and umbilicalcord pH. A higher incidence of intermediate andsevere laceration as well as higher rates ofepisiotomy have been found in the mixed group (i.e.mainly on the back birthing position). Regardingour results and considering the literature weconclude that the upright birthing position bringsno discredit upon newborn or the maternal perineum.

Kleine-Tebbe A, David M, Farkic M. [Uprightbirthing position--more birth canal injuries?Results of a retrospective comparative study].[article en allemand].Zentralbl Gynakol. 1996;118(8):448-52.


Un plaidoyer pour laflexibilité.

[1106] The authors trace the use of birthing stoolsand their decline as the recumbent position becamethe predominant one for giving birth. Theadvantages of upright positions are summarised,supporting the idea that women should be allowedmore flexibility and movement in labour andrecommending that birthing stools be reintroducedas an option for delivery. Adequate antenatalpreparation in the use of different positions, andencouragement from midwives and obstetricians, willhelp make childbirth a safer, more collaborativeand satisfying experience as recommended by theWinterton Report.

Nelki J, Bond L. Positions in labour: a plea forflexibility.Mod Midwife. 1995 Feb;5(2):19-22.




Etude de cohorte.L'application decompresses chaudeset la lubrificationsont des facteurs derisque dedéchirures. Parcontre le maintienmanuel du périnéediminue ce risque.La positionlithotomiqueaugmente lafréquence desépisiotomies.

[1161] This article describes the association amongperineal outcomes, selected risk factors, andalternative intrapartum approaches used by nurse-midwives. This nonrandomized concurrent (cohort)study analyzed all spontaneous vaginal births (N =1211) attended by nurse-midwives at a universityhospital over a 2-year period. Univariate analysiswas used to calculate relative risks for theassociations between two perineal outcomes andselected variables. Study results indicated thatparity, ethnicity, birth weight, and use of twotechniques (hot compresses and lubrication) wereassociated with lacerations. The same factors thatincrease the risk of perineal lacerations also madethe performance of an episiotomy more likely;however, for episiotomy, an inverse relationshipwith perineal hot compresses was noted, andperineal lubrication had no effect. Lack ofperineal support was associated with a 66% rise inthe risk of episiotomy. Use of birthing positionsother than lithotomy significantly reduced thelikelihood of episiotomy. The authors concludedthat selected care measures to protect the perineummay reduce maternal morbidity and simplifyintrapartum care. The risks and benefits ofalternative strategies commonly used by nurse-midwives while caring for diverse populationsduring birth should be further evaluated in largemultiethnic populations.

Lydon-Rochelle MT, Albers L, Teaf D. Perinealoutcomes and nurse-midwifery management.J Nurse Midwifery. 1995 Jan-Feb;40(1):13-8.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7869144[1169] PIP: In 1992 at Vivekanand Hospital inLatur, Maharashtra State, India, researchersrandomly allocated 326 pregnant women, 15-45 yearsold, at full term, to either the modified squattingposition group (study group) or the normallithotomy delivery position group (control group)to determine whether the modified squattingposition using a birth cushion has any advantagesover the normal delivery position. The U-shapedcushion is inexpensive, constructed with coir andfoam, and has a washable cover. Its two handlesprovide the woman support as she pushes anddelivers the newborn. There were 145 women in thestudy group and 181 in the control group. Women inthe squatting position did not receive anyepisiotomies. They spent less time pushing (i.e.,in second stage of labor) than those in the controlgroup (median, 21.2 vs. 39.32 min; p 0.01),especially among gravidae 2 and above. The time



required to perform vaginal operative delivery wasmuch shorter for the squatting position than forthe normal delivery position (11.6 vs. 28.86 min; p0.01). Fetal stress was more common among newbornsdelivered by the normal delivery position thanamong those delivered by the squatting position(7.73% vs. 3.44%; p 0.05). Women in the squattinggroup were more likely to have an intact perineumafter delivery than those in the control group.None of the women in the control group hadpostpartum vulval edema, while five in the studygroup did. The edema was mild, however, andresolved itself within 24 hours of delivery. Mostwomen in the squatting position group weresatisfied with this position. These findingssuggest that the squatting position using a birthcushion has more benefits than the normal deliveryposition. It allows better coordination and moreeffective pushing. Traditional birth attendants andfemale health workers at subcenter and primaryhealth center levels can be trained to use thebirth cushion during labor.

Bhardwaj N, Kukade JA, Patil S, Bhardwaj S.Randomised controlled trial on modified squattingposition of delivery.Indian J Matern Child Health. 1995 Apr-Jun;6(2):33-9.


Recommandationd'excercices douxd'assouplissementsdu bassin et du dosjusqu'au 4-6e moisde grossesse. Lessages-femmesdevraient bienconnaitre laphysiologie desdifférentespositionsd'accouchement.

[1131] Early in pregnancy it is useful to encouragethe mother to do some gentle exercise to offsetsome of the mechanical strain that will arise withpostural changes. Manipulation of the lumbar spineand pelvic joints is possible until the sixth monthfor primigravidae and the fourth or fifth month formultiparae. The joints and soft tissues willrespond very readily to gentle stretchingtechniques because of hormonal changes. It isappropriate for midwives to have a good workingknowledge of the mechanical advantages anddisadvantages of different maternal positionsadopted during labour.

Parsons C. Back care in pregnancy.Mod Midwife. 1994 Oct;4(10):16-9.


Cette étude suédoisetrouve 4 fois plusdéchirures du3edegré dans lespositionsd'accouchementverticales (àgenoux, quatre

[1132] BACKGROUND: During the past years a majorchange in the use of delivery position has occurredin Sweden. Recumbent delivery positions have beenreplaced by a variety of positions: squatting,standing, lateral, kneeling and quadruped. Theconsequences of this shift in obstetrical practicefor development of perineal lacerations are largelyunknown.



pattes, debout,…)qu’en positionassise. Pas dedifférence sur lasanté du nouveau-né.

METHOD: Retrospective comparison of uncomplicateddeliveries in standing (n = 650) and sitting (n =264) position with respect to third degreelacerations.

RESULTS: The standing and sitting delivery groupwere similar with respect to maternal, infant anddelivery characteristics. The frequency of thirddegree tears was 2.50% in standing and 0.38% insitting birth position (p < 0.05). In nulliparouswomen, third degree tears occurred in 4.2% instanding and 1.0% in sitting position.

CONCLUSION: The present data implies that the riskof third degree lacerations is considerably higher(7 x) in standing than in sitting birth positions.

Gareberg B, Magnusson B, Sultan B, Wennerholm UB,Wennergren M, Hagberg H. Birth in standingposition: a high frequency of third degree tears.Acta Obstet Gynecol Scand. 1994 Sep;73(8):630-3.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7941987[1133] OBJECTIVE: To review reports of the supinehypotensive syndrome with reference to clinicalpresentation, suggestions on the mechanism ofonset, and the possibility of advance detection.

DATA SOURCES: We used worldwide obstetric,anesthesia, and general medical journals from 1922onward, a Medline search from 1966 onward, andmanual cross-referencing for prior publications.

METHODS OF STUDY SELECTION: We selectedapproximately 100 case reports of supinehypotensive syndrome and studies on supine bloodpressure responses during late pregnancy.

DATA EXTRACTION AND SYNTHESIS: Publications thatrecorded novel clinical observations, specifichemodynamic or biochemical measurements, orassociated complications were included.

CONCLUSIONS: Supine hypotensive syndrome ischaracterized by severe supine symptoms andhypotension in late pregnancy, which compel theunconstrained subject to change position. Rarely,it may manifest even from the fifth month ofpregnancy or postpartum, as well as in the pelvictilt or sitting positions. Although inferior venacava compression, influenced primarily by the sizeof the uterus and exact maternal and fetalposition, is the major determinant in itsdevelopment, other factors may also be important inmodulating the circulatory effects of suchcompression. Advance recognition of susceptibility



to the syndrome depends on a history of severesupine symptoms or supine intolerance and anincrease in maternal heart rate and decrease inpulse pressure in the supine position. As thereseems to be a spectrum of severity from minimalcentral cardiovascular alterations to severesyncopal shock resulting from supine inferior venacava compression, it is difficult to define acutoff point at which the syndrome occurs. Althoughusually recognizable by maternal symptoms, severehypotension without symptoms has been reported onthree occasions.

Kinsella SM, Lohmann G. Supine hypotensivesyndrome.Obstet Gynecol. 1994 May;83(5 Pt 1):774-88.

La position allongée sur le dos en fin de grossesseou pendant l'accouchement favorise des baisses dela tension maternelle pouvant aller, bien querarement, jusqu'à la syncope. La pression sur laveine est incriminée, maid d'autres facteurspourraient ètre aussi impliqués.[1176] During 1992, 140 women out of a total of1122 used the delivery chair at the department forobstetrics and gynaecology at the LKH Modling. Wecompared them to a control group in the supineposition. In order to evaluate the safety ofdeliveries on the delivery chair, we studied theduration of the stages of labour, rate and degreeof soft tissue injuries, maternal blood loss, fetaloutcome and complications in the puerperium. Theuse of the delivery chair showed no increased riskto either the mother or the fetus and thereforerepresents an appropriate alternative to thetraditional supine position for delivery.

Kafka M, Riss P, von Trotsenburg M, Maly Z. [Thebirthing stool - an obstetrical risk?] [Article inGerman].Geburtshilfe Frauenheilkd. 1994 Sep;54(9):529-31.


Une revue desmauvaise pratiques…Les changements deposition et lespositions non-conventionnellesaugmentent leconfort etl’efficacité dutravail.

[1107] Some practices and procedures that arecommon during the management of childbirth lackproof of efficacy, and some have adverse effects.The practice of withholding food and liquids andusing intravenous fluids during labor may poserisks such as fluid overload, and maternal andfetal hyperglycemia. Enemas should be reserved forwomen with painful constipation. Evidence does notsupport the value of shaving the perineal area.Nonpharmacologic measures to control pain duringlabor are safe and moderately effective.Pharmacologic methods of analgesia and anesthesiaprovide good pain relief but pose significantrisks. Continuous electronic fetal monitoring



should be considered a diagnostic procedure, not ascreening procedure. Amniotomy may shorten laborbut can result in abnormally high uterine forces,infection, umbilical cord prolapse and fetallaceration. Position changes and alternative birthpositions promote greater comfort and efficiencyduring labor. Finally, episiotomy has not beenshown to reduce severe lacerations or preventpelvic relaxation, and use of this procedure shouldbe limited.

Smith MA, Ruffin MT 4th, Green LA. The rationalmanagement of labor.Am Fam Physician. 1993 May 1;47(6):1471-81.


L’accouchement estplus rapide à quatrepattes qu'enposition semi-allongée, avec moinsde déchiruressévères et moinsd'interventions.

[1153] A cohort study was designed to assess theeffects of maternal squatting position for thesecond stage of labor on the evolution and progressof labor, and on maternal and fetal well-being.Outcomes from 200 squatting births, randomlyselected from a sample of 1000, were compared with100 semirecumbent births, randomly selected from asample of 300. Data collection was by chart review.The two groups were similar with respect to mostantepartal, intrapartal, and socioeconomicvariables likely to affect labor outcomes. The meanlength of the second stage of labor was 23 minutesshorter in squatting primiparas and 13 minutesshorter in squatting multiparas than insemirecumbent women. Squatting women requiredsignificantly less labor stimulation by oxytocinduring second stage (P = 0.0016), and they showed atrend toward fewer mechanically assisteddeliveries. Significantly fewer and less severeperineal lacerations occurred, and fewerepisiotomies were performed in the squatting group(P = 0.0001). No statistically significantdifferences were found between groups for third-stage complications and infant complications.

Golay J, Vedam S, Sorger L. The squatting positionfor the second stage of labor: effects on labor andon maternal and fetal well-being.Birth. 1993 Jun;20(2):73-8.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8240610[1167] This study was conducted at the LokmanyaTilak Municipal General Hospital, Bombay, Indiaduring the year 1990. The aim was to compare theroutinely used supine position versus ambulation inthe first stage and squatting position during thesecond stage of labour. Our study was comprised of200 patients both primigravidas and multigravidas;100 were kept in the supine position throughoutlabour and 100 were kept ambulatory in the first



stage and adopted the squatting position during thesecond stage. The study showed a shortening of bothstages of labour in the squatting group but theincidence of complications was less in the controlgroup. It was concluded that without properbirthing chairs which can give excellent perinealsupport, the usual supine position is preferable inour setup.

Allahbadia GN, Vaidya PR. Why deliver in the supineposition?Aust N Z J Obstet Gynaecol. 1992 May;32(2):104-6.


Le sièged’accouchement neprésente pasd’avantages sur laposition allongée.(Sans péridurale)

[975] OBJECTIVE--To determine whether nulliparaewhose second stage of labour is conducted in anobstetric birth chair have a lower incidence ofinstrumental delivery than those using aconventional delivery bed.

DESIGN--Randomized controlled trial using sealed,opaque envelopes for allocation.

SETTING--Delivery ward in a busy teaching hospital.

PATIENTS--1250 nulliparae with a singleton livefetus with cephalic presentation, without epiduralanaesthesia, who had achieved full dilatation.

INTERVENTION--Intention to conduct second and thirdstages of labour in either the Birth-EZ chair orthe conventional delivery bed, as randomlyallocated.

MAIN OUTCOME MEASURES--Primary measure: vaginaloperative delivery; principal secondary measures:duration of second stage, perineal trauma, bloodloss, women's views, and neonatal status.

RESULTS--Delivery in the birth chair did not resultin a reduction in operative delivery, overall.However, there was a reduction in vaginal operativedelivery for fetal heart rate abnormality. Therewas no beneficial effect on perineal trauma orpuerperal perineal pain. Post-partum haemorrhagewas more frequent in the birth chair group.

CONCLUSIONS--Delivery in the birth chair does notoffer any obvious advantage to women over deliveryon a bed.

Crowley P, Elbourne D, Ashurst H, Garcia J, MurphyD, Duignan N. Delivery in an obstetric birth chair:a randomized controlled trial. Br-J-Obstet-Gynaecol. 1991 Jul; 98(7): 667-74

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=R



etrieve&db=PubMed&list_uids=1883790&dopt=AbstractEtude limitée audébut du travail. Ladouleur estnettement diminuéedans les positionsverticales parrapport à laposition allongée,toutparticulièrementpourla douleur dans lesreins.

[1134] The purpose of this study was to determinewhether women in labor report less pain when theyare in a vertical (sitting or standing) positionthan in a horizontal (side-lying or supine)position. Pain scores were obtained from 60 womenin early labor (dilation 2-5 cm) who alternatedbetween the two positions. The results show thatabout 35% of women feel less front pain and 50%feel less back pain when they are in a verticalposition than in a horizontal position. Thedecrease in continuous back pain (83%) wasparticularly impressive, but the front and backpains associated with contractions weresignificantly diminished as well. These results,taken together with those of earlier studies,indicate that many women in early labor have lesspain and are generally more comfortable in avertical than in a horizontal position. Since earlylabor comprises a substantial proportion of theentire process of labor and delivery, any simpleprocedure which alleviates pain without danger tomother or child, such as shifting from a horizontalto a vertical position, should be promoted andemployed.

Melzack R, Belanger E, Lacroix R. Labor pain:effect of maternal position on front and back pain.J Pain Symptom Manage. 1991 Nov;6(8):476-80.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=1835474[1165] Two hundred ninety-four women were randomlyallocated to a group in which the use of a birthingstool (experimental group) or a conventionalsemirecumbent position (control group) wasencouraged. The birthing stool was 32 cm high andallowed the parturient to sit upright and to squat.The husband could sit close behind his wife andsupport her back. No differences were observedbetween the two groups regarding mode of delivery,length of the second stage of labor, oxytocinaugmentation, perineal trauma, labial lacerations,or vulvar edema. Infant outcome measured by Apgarscores at 1 and 5 minutes postpartum and numbers ofneonatal intensive care unit transfers was the samein both groups. Mean estimated blood loss and thenumber of mothers with a postpartum hemorrhage 600ml or more were greater in the experimental groupthan in the control group. Women in theexperimental group reported less pain during thesecond stage of labor, and they and their spouseswere more satisfied with the birth position thanwere parents in the control group. Midwives wereless satisfied with their working posture in theexperimental group.

Waldenstrom U, Gottvall K. A randomized trial of



birthing stool or conventional semirecumbentposition for second-stage labor. Birth. 1991Mar;18(1):5-10.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=2006963[1136] This study was undertaken to investigate theoutcome of epidural catheter insertion in thesitting or lateral position in mothers duringlabour. An initial prospective randomised studyperiod (144 patients) suggested that the sittingposition offered some superiority over the lateralin terms of technical ease of insertion. It wasconcluded, by minimising the subjective aspects ina follow-up, prospective nonrandomised study period(152 patients), that the determining factor lies inthe skill and experience of the anaesthetist. Therewas no significant difference in complication ratesor maternal discomfort between the two positions ineither study period.

Stone PA, Kilpatrick AW, Thorburn J. Posture andepidural catheter insertion. The relationshipbetween skill, experience and maternal posture onthe outcome of epidural catheter insertion.Anaesthesia. 1990 Nov;45(11):920-3.

Comparaison des positions assises et decubituslatéral pour la pose de la péridurale. Pas dedifférences notables, l'expérience del'anesthésiste étant primordiale.

Etude de cohorte enmilieu rural (USA).Les multiparesdonant naissance enposition semi-assiseontsignificativementmoins de déchiruresqu'en positionlithotomique.

[1137] A study to evaluate the relationship betweenmaternal birthing position and perineal outcome wasundertaken on 335 patients in a rural familyphysician's practice whose babies were deliveredvaginally between December 1980 and December 1988.The most common birthing position used by the womenwas the semi-sitting position in the birthing bed(44%, n = 146). Ninety-four women (28%) gave birthfrom the conventional lithotomy position, 80 (24%)used the birthing chair, and less than 5% used aside-lying position. Almost 30% of the women gavebirth with intact perineum; the incidence ofepisiotomy was 44%. The use of a particularposition for delivery varied with parity, andmultiparous women used the semi-sitting position inthe birthing bed more frequently than didprimiparous women. There was no statisticallysignificant relationship between birthing positionand perineal outcome for primiparous women. Astatistically significant relationship betweendelivery position and perineal outcome was foundfor multiparous women. Multiparous women using thebirthing bed were more likely to have less perinealtrauma than women giving birth on the deliverytable.

Olson R, Olson C, Cox NS. Maternal birthing



positions and perineal injury.J Fam Pract. 1990 May;30(5):553-7.


Etude contrôléerandomisée concluantque le premier stadedu travail est plusrapide en positionverticale qu'enposition couchée.Sans incidence surle "confort" desfemmes en couches nisur la santé dunouveau-né.

[1138] The purpose of this study was to determineif women who assumed upright positions during thephase of maximum slope would have a shorter phaseof maximum slope in their labor and experience morecomfort than women who assumed recumbent positions.Forty laboring women were randomly assigned toeither an upright or recumbent position group.Subjects assumed the positions of their assignedgroup during the phase of maximum slope in theirlabor (cervical dilatation from 4 cm to 9 cm).Every hour during the phase of maximum slope, eachsubject was examined vaginally to determine hercervical dilatation and assessed for her level ofcomfort using the Maternal Comfort Assessment Tool.Women in the upright position group had asignificantly shorter phase of maximum slope inlabor, but did not significantly differ in comfortlevel from women in the recumbent group. NewbornApgar scores were not significantly differentbetween the two groups. Nurses need to be awarethat the upright labor positions have the distinctadvantages of facilitating efficient uterinecontractions and reducing the duration of the phaseof maximum slope in labor, with no increase in thediscomfort experienced or adverse effect on newbornwell-being.

Andrews CM, Chrzanowski M. Maternal position,labor, and comfort.Appl Nurs Res. 1990 Feb;3(1):7-13.


La positionlithotomiqueaccentueraitl’étirement dupérinée.

[54] Le groupe étudié était composé de 241 femmesnullipares ayant eu un accouchement spontané, envertex, non multiple. Le taux d’épisiotomies a étéde 46.1%. Des sages-femmes ont accompagné 65.1% desnaissances, les autres ayant été confiées à desobstétriciens. Les médecins ont plus souvent faitappel aux étriers (p < 0.01). Parmi les 174 femmesqui ont accouché dans une position différente, lesplus nombreuses étaient en position semi-assise (N= 153).

Les taux d’Apgar n’ont eu aucune corrélation avecl’épisiotomie.

Le lacérations “profondes” (du troisième ouquatrième degré) on été les moins nombreuses (0.9%)chez les femmes qui n’ont pas subi d’épisiotomie etn’étaient pas en position lithotomique, et les plusnombreuses (27.9%) chez celles qui étaient dans lesdeux cas de figure. Pour celles qui étaient dans un



seul des deux cas, les résultats étaientintermédiaires. L’épisiotomie était fortementcorrélée aux déchirures profondes (odd ratio de22.46, CI 7.81-64.61, p < 0.003) ainsi qu’à laposition lithotomique (odd ratio de 14.01, CI 4.18-47.28, p < 0.029). Le rôle joué parl’accompagnant(e) n’a pas été élucidé. Les médecinsont été associés à un taux plus important dedéchirures, mais ils pratiquaient plusd’épisiotomies et utilisaient plus souvent lesétriers. Cela reflète peut-être le fait qu’ilsétaient appelés en cas de problème. Après avoirajusté les données en fonction des étriers et del’épisiotomie, l’association des médecins auxdéchirures profondes n’était plus visible.[Toutefois, les médecins ont plus tendance àutiliser la position lithotomique et à faire desépisiotomies, y compris en l’absence decomplications.]

Une explication possible de la relation entrel’usage des étriers et les déchirures profondes estque la position lithotomique accentue l’étirementdu périnée.

[Résumé tiré de Goer, H. Obstetric Myths VersusResearch Realities: A Guide to the MedicalLiterature. Westport: Bergin & Garvey, 1995: 292.Les remarques entre crochets sont d’Henci Goer.]

Borgatta, L.; Piening, SL.; Cohen, WR. Associationof episiotomy and delivery position with deepperineal laceration during spontaneous delivery innulliparous women. Am. J. Obstet. Gynecol., 1989,160(2): 294-297

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2916609&dopt=Abstract[1172] A controlled clinical trial involving 151primigravidae and 18 midwives assessed theacceptability and outcome of second-stage labour inupright positions. Women who had no specificantenatal preparation and preferences regardinglabour positions were managed either conventionally(semi-recumbent and lateral), or encouraged toadopt upright positions (squatting, kneeling,sitting or standing) according to individualpreference. Of the women allocated to the uprightposition 74% completed the second stage upright,with kneeling being the most favoured position, butsquatting was, despite all assistance, toodifficult to maintain. Adoption of uprightpositions resulted in a higher rate of intactperineums. There was a clinically apparentreduction of forceps deliveries in the uprightgroup which influenced midwives' attitudes. Movingthe parturient from recumbent to upright positionswas often perceived to be beneficial when there was



slow progress. Estimated blood loss was similar inthe two groups, as was the condition of the newborn(Apgar score and umbilical artery pH). Alternativepositions in the second stage of labour, inparticular kneeling, are achievable even withoutspecific birth aids and antenatal preparation. Theyappear safe, acceptable to most parturients andtheir midwives, and are easily integrated intomodern labour ward practice; they may have clinicaladvantages which need further investigation.

Gardosi J, Sylvester S, B-Lynch C. Alternativepositions in the second stage of labour: arandomized controlled trial.Br J Obstet Gynaecol. 1989 Nov;96(11):1290-6.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=2692698[1174] A new obstetric aid, the 'Birth Cushion'allows the parturient to sink into a supportedsquatting posture for the second stage of labourand delivery; it fits onto conventional deliverybeds. A prospective, controlled trial of 427primiparae compared the outcome of labour in womenrandomly allocated to squatting (218) orconventional semirecumbent (209) management. Thesquatting group had significantly fewer forcepsdeliveries (9% vs 16%) and significantly shortersecond stages (median length of pushing 31 vs 45min) than the semirecumbent group. There were fewerperineal tears, but more labial tears, in thesquatting group. Apgar scores, blood loss, andpost-partum vulvar oedema were similar in bothgroups. 82% of the women in the squatting groupmaintained upright positions for most of the secondstage, and reported great satisfaction with thesupported squatting position. The traditional birthposture of squatting can be easily adapted formodern labour management and has advantages forwomen in their first labour.

Gardosi J, Hutson N, B-Lynch C. Randomised,controlled trial of squatting in the second stageof labour.Lancet. 1989 Jul 8;2(8654):74-7.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=2567873[1179] The purpose of this investigation was toreplicate an earlier study to clarify and verifyits findings. The 68, term primigravidae marriedwomen between the ages of 18 and 25 years wereassigned to three groups: (a) one group used a 30degree upright position with no bearing downinstructions during the second stage of labor (n =24); (b) the second group used a 30 degree uprightposition with bearing down instructions givenduring the second stage of labor (n = 22); and (c)



a control group used a zero degree recumbentposition with bearing down instructions during thesecond stage of labor (n = 22). The uprightposition enhanced the descent of the fetal headwith a shorter duration of labor in both the firstand second stages. When mothers in an uprightposition were left alone to bear down in responseto their own bodies' urges, the second stage oflabor was of shorter duration.

Liu YC. The effects of the upright position duringchildbirth.Image J Nurs Sch. 1989 Spring;21(1):14-8.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=2925211[1191] A prospective quasi-experimental study wasconducted to determine women's perceptions of theirchildbirth experiences using a birth chair. Thesample consisted of 55 primiparas, from 37 to 41gestational weeks, with normal pregnancy and labor;22 women delivered on a traditional delivery table(DT), and 33 women used a birth chair (BC). Aquestionnaire consisting of 21 items on a five-point scale (the higher the score, the morepositive the perception) was self-administered bysubjects during postpartum hospitalization. Nosignificant differences were found between groupson overall score. However, women using the birthchair had a significantly higher score on thecomfort subscale, as did women who had attendedprepared childbirth classes.

Shannahan MK, Cottrell BH. The effects of birthchair delivery on maternal perceptions.Journal of Obstetric, Gynecologic, and NeonatalNursing; 1989:18(4)323-326

Etude randomiséecontrôlée comparantl'accouchement avecune chaise spécialeà la positionlithotomique(incluant ledécubitus latéral).Aucun avantage n'esttrouvé àl'utilisation decette chaise aveclaquelle on observeplus d'hémorragiespost-partum.

[1193] A new obstetric chair has been designed toovercome some of the problems of those currentlyavailable commercially. The chair has been used toassess the effects of the sitting position in thesecond stage of labour on the outcome of deliveryin 304 women randomly allocated to be deliveredeither in the chair or in the conventional dorsalposition. Delivery in the chair conferred nobenefits to mother or baby and resulted in greatermean blood loss and a higher rate of postpartumhaemorrhage.

Stewart P, Spiby H. A randomized study of thesitting position for delivery using a newlydesigned obstetric chair.Br J Obstet Gynaecol. 1989 Mar;96(3):327-33.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=2785402[1215] X-ray pelvimetry was performed on 43 womenin the squatting and erect positions within 1 week



of delivery. The act of squatting increased thetransverse and antero-posterior pelvic dimensionsby 1%. The theoretical mechanisms by which posturemay affect dimensions are discussed.

Lilford RJ, Glanville JN, Gupta JK, Shrestha R,Johnson N. The action of squatting in the earlypostnatal period marginally increases pelvicdimensions.Br J Obstet Gynaecol. 1989 Aug;96(8):964-6.


Le foetus est mieuxoxygéné lorsque lesfemmes accouchent enposition verticale.

[1140] We performed umbilical blood gas analysisfor 130 pregnant women in sitting and for 50 insupine position immediately after their deliveries.To elucidate whether fetal blood gas changes wereattributed to the maternal postures, we alsocarried out the maternal blood gas analysis duringdelivery (n = 145) and prior to the onset of labor(n = 100) in both positions. Blood gas values ofthe umbilical vein and artery in the sitting groupwere significantly higher in pH, PO2, base excess(BE) and oxygen saturation (SO2), and lower in PCO2than those in the supine group. In contrast,maternal blood gas values (pH, PaCO2, PaO2 andSaO2) did not show significant differences betweenthese two groups in both during delivery and beforethe onset of labor. Thus, the sitting deliveryposition can elicit physiologically more beneficialblood gas aspects in fetus compared with theconventional supine delivery position. Umbilicalblood gas improvements induced by sitting deliveryposition do not appear to be a result of thematernal blood gas alteration, but appear to bemediated by other factors.

Koga S, Koga Y, Nagai H. Physiological significanceof fetal blood gas changes elicited by differentdelivery postures.Tohoku J Exp Med. 1988 Apr;154(4):357-63.


L'observation del'accouchement chezles Papous suggèrentdes avantages à laposition verticale.

[1108] During an ethnomedical field study theauthor succeeded in participating and photographing4 traditional birthgivings among theTrobrianders/Papua New Guinea. Their variousvertical postures are described with specialreference to specific Trobriand practices anddiscussed by literature review. The results suggestthat vertical birthing positions are advantageousto horizontal ones and should be reconsidered bymodern Western obstetrics.

Poschl U. The vertical birthing position of theTrobrianders, Papua New Guinea.Aust N Z J Obstet Gynaecol. 1987 May;27(2):120-5.




La position assiseplutôt que couchéepourrait aider àréduiresignificativement ladurée du travail.

[1113] To determine which components of uterineactivity are affected by different positions oflabor, 116 intrauterine pressure records in thesitting and supine positions were analyzed in orderto measure resting, contraction, and bearing downpressures. The resting pressure in the sittingposition showed consistent elevation compared tothe supine position, while the contraction pressuredid not differ strikingly in the two positions. Thebearing down pressure in the sitting position fornulliparas during the second stage and formultiparas at the time of the 8- to 10-cm dilationwas significantly higher than that in the supineposition. Also, the sitting position led to asignificantly shorter duration of the second stagein nulliparas and the 5- to 10-cm dilation periodin multiparas. These findings suggest that thematernal position does not affect uterinecontractility, that the increased resting pressurein the sitting position is of some importance insupplementing the downward delivery force, and thatthe increased bearing down pressure in the sittingposition could help to significantly shorten theduration of labor.

SZ Chen, K Aisaka, H Mori, and T Kigawa. Effects ofsitting position on uterine activity during laborObstetrics & Gynecology 69:67-73

http://www.greenjournal.org/cgi/content/abstract/69/1/67

Comparaison des tauxd'oxygène et CO2 enpositionlithotomique et surune chaised'accouchement pourdes primipares.Moins de CO2artériel avec leschaises, tauxd'oxygène identique.

[1141] This study was conducted to determine theeffect of the birth chair on fetal outcome inprimigravid subjects with a normal pregnancy andlabor. A quasi-experimental design was used tocompare 33 birth-chair deliveries with 22 delivery-table deliveries. No difference between groups wasfound in the mean pH and pO2 of arterial and venouscord blood samples. The mean arterial pCO2 waslower in the chair group (49.25 and 44.50, p =0.023), but there was no difference in venous pCO2.In the chair group, the mean vein pO2 was higherwhen the angle of the chair was more than 45degrees upright (22.3 and 28.4, p = 0.007). Meansfor chair and table groups were similar formaternal hemoglobin, breathholding while pushing,duration of second stage, time of first cry, timeof cord clamping, and Apgar scores. Incidence ofcord around the neck was identical. The mean one-minute Apgar scores were significantly higher whenchair or table was more than 30 degrees upright(8.0 and 8.59, p = 0.037). Results suggest that thebirth chair is a safe alternative to the deliverytable in terms of fetal outcome. The findings oflower arterial pCO2 with unchanged pO2 and pH in



the chair group, support earlier findings of lesstransient cord compression in upright positions.

Cottrell BH, Shannahan MK. A comparison of fetaloutcome in birth chair and delivery table births.Res Nurs Health. 1987 Aug;10(4):239-43.


Les positions etchangements depositions spontanéspendant le travailpréviennent ourésolvent lesdystocies.

[1142] Women have always used different positionsto make labor more comfortable and, when allowed,spontaneously change position numerous times duringlabor and birth. The positions they choose, whiledictated by comfort, frequently prove to bebeneficial in promoting labor progress. For 50years, the value of mobility and position changereceived little attention, but recent research andadvances in the design of birthing equipmentindicate that maternal positioning provides avaluable, noninvasive, and acceptable intervention.This paper reviewed six mechanisms by whichdystocia may be prevented or corrected through theuse of maternal positioning.

Fenwick L, Simkin P. Maternal positioning toprevent or alleviate dystocia in labor.Clin Obstet Gynecol. 1987 Mar;30(1):83-9.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=3555921[1160] The effect of position during the secondstage on outcome was studied in 58 women, with noexclusions because of pregnancy complications orsigns of fetal distress, who were randomlyallocated to have the second stage conducted ineither the dorsal or 15 degrees lateral tiltposition. All the women were of parity 0 or 1 andthe two groups were well matched except forgestational age at delivery. There were nodifferences in clinical outcome between the twogroups, but overall the dorsal group had lower cordartery pH values (P less than 0.05), higher PCO2 (Pless than 0.01) and a greater base deficit, but notsignificantly so. pH and base deficit were similarin both groups where the second stage did not lastgreater than 15 min. Thereafter, there was a trendto decreasing pH and increasing base deficit withincreasing length of second stage in the dorsalgroup, but not in the tilt group though this didnot reach statistical significance. Low Apgarscores, complicated pregnancy and first pregnancywere each associated with significantly lower pHlevels. Prolonged placement of the patient in theflat dorsal position should be avoided in secondstage, though a suitable alternative under theconditions described has not been defined.

Johnstone FD, Aboelmagd MS, Harouny AK. Maternal



posture in second stage and fetal acid base status.Br J Obstet Gynaecol. 1987 Aug;94(8):753-7.

Laisser les femmeslibres de déciderleur positiond'accouchement etleur respirationn'est pas risqué.

[1109] An observational study was done on thepositions and breathing techniques women willchoose for second-stage labor when they are giventhe freedom and support to choose. In the 50 secondstages and births observed, nine differentpositions were used in conjunction with threevariations of expulsive breathing techniques. Noadverse outcomes resulted from the nonprescriptiveapproach to birthing women. All outcome parameterswere found to be within the range of normal. Thesefindings support the acceptability of allowingwomen to respond to their birthing impulses.Further study is recommended to verify the safetyof a nondirective approach to birth.

Rossi MA, Lindell SG. Maternal positions andpushing techniques in a nonprescriptiveenvironment.J Obstet Gynecol Neonatal Nurs. 1986 May-Jun;15(3):203-8.


Laissées libres dechoisir, les femmeschoisissentdifférentespositions pendant letravail.

[1115] While controversy exists as to therelationship between maternal position in labor andsuch measures as the labor duration, subjectivediscomfort, and fetal outcome, little appears to beknown about the positions women assume in laborwhen they are permitted to do so without coercionor instruction. To learn more about maternalposition in labor, we observed 80 consecutivepatients with uncomplicated normal spontaneousvaginal delivery over the course of labor toascertain the positions volitionally chosen byeach. Data were collected on position preferencesand phase of labor. All labors were analyzed; acodified lexicon was established to describe theposition pattern in each phase and the principalpositions the patient assumed over the course oflabor. The frequencies and distributions weredetermined for nulliparas and multiparas separatelyand rates of position change were assessed. It wasfound that gravidas chose a number of differentprincipal positions in the early phases of labor,but that they became more narrowly selective in thedeceleration phase and second stage; at the sametime, they tended to change position more often inlate labor.

JM Carlson, JA Diehl, M Sachtleben-Murray, M McRae,L Fenwick, and EA Friedman. Maternal positionduring parturition in normal laborObstetrics & Gynecology 68:443-447

http://www.greenjournal.org/cgi/content/abstract/68/4/44



Revue. Bien que lesdonnées examinées neprouvent pas que ladéambulationaccélère le travailou améliore l'étatdu bébé, il estnéanmoins clairqu'elle n'est enrien dangereuse, etqu'elle améliore leconfort de la femmeen coucheset diminuela demandeanalgésique.

[1202] There has been a relatively recent interestin alternative birthing techniques, includingincreased maternal mobility during labor. Thisliterature review was pursued to evaluate theeffect of upright maternal posture and ambulationon the first stage of labor. Although previousreviews frequently assume that maternal ambulationspeeds labor progress, the data presented in thisreview are not conclusive as to whether the uprightmaternal posture or ambulation during the firststage of labor shortens labor length or improvesfetal outcome. However, it is clear that ambulationin labor is not harmful either to the mother orfetus. In addition, many investigators havereported that mobility in labor results in greatermaternal comfort and ability to tolerate labor anddecreased use of anesthesia and analgesia. Thus,acceptance of mobility in labor by patients andstaff is generally reported. This information canserve as a guide to clinical management. However,there is a need for further analysis of the effectof maternal ambulation during labor, and specificsuggestions for research are presented.

Lupe PJ, Gross TL. Maternal upright posture andmobility in labor--a review.Obstet Gynecol. 1986 May;67(5):727-34.

Pour 20% despatientes unedécéleration durythme cardiaque dufoetus a été montréequand la patienteétait en positionallongée.

[1094] Presented is an investigation of therelationship of fetal heart rate (FHR) decelerationand position of the patient in labor. In a group of902 laboring patients, 126 (14%) demonstrated latedecelerations. Of the 126, 24 (19%) patientsdemonstrated late decelerations in the supineposition only. These occurred during uterinecontractions and were associated with reducedfemoral arterial blood pressure and amplitude ofthe capillary pulse of the big toe. A drop incapillary blood pH of the fetal scalp could also bedemonstrated. These effects reproducibly appearedand disappeared when supine and lateral positionswere alternated. These data would suggest thatmaternal aortic compression by the pregnant uterusplays a role in the etiology of fetal stress asexpressed by changes in fetal heart rate and acidbase balance. This effect can be evaluated andmonitored simply by recording the pulse pressure ofthe big toe and femoral arterial pressure. Theseatraumatic procedures can be applied to anypatient.

ABITBOL MM. SUPINE POSITION IN LABOR AND ASSOCIATEDFETAL HEART-RATE CHANGESOBSTETRICS AND GYNECOLOGY 65 (4): 481-486 1985

http://www.greenjournal.org/cgi/content/abstract/65/4/481[1110] The evidence supporting upright positions inchildbirth and concerns about squatting are



reviewed. Squatting techniques and how to adaptthem to the traditional birth setting areexplained, and the role of attitude on the part ofchildbirth educators and birth attendants in makingthe squatting position practically available forwomen in childbirth is emphasized. Recommendationsare made for future research.

Romond JL, Baker IT. Squatting in childbirth. A newlook at an old tradition.J Obstet Gynecol Neonatal Nurs. 1985 Sep-Oct;14(5):406-11.


Observation d'unebaisse de lapression dansl'artère fémorale,associée à une moinsbonne irrigation dufoetus, chez 20% desfemmes en positionlithtomique. Effetnon observé endécubitus latéral.

[1143] Presented is an investigation of therelationship of fetal heart rate (FHR) decelerationand position of the patient in labor. In a group of902 laboring patients, 126 (14%) demonstrated latedecelerations. Of the 126, 24 (19%) patientsdemonstrated late decelerations in the supineposition only. These occurred during uterinecontractions and were associated with reducedfemoral arterial blood pressure and amplitude ofthe capillary pulse of the big toe. A drop incapillary blood pH of the fetal scalp could also bedemonstrated. These effects reproducibly appearedand disappeared when supine and lateral positionswere alternated. These data would suggest thatmaternal aortic compression by the pregnant uterusplays a role in the etiology of fetal stress asexpressed by changes in fetal heart rate and acidbase balance. This effect can be evaluated andmonitored simply by recording the pulse pressure ofthe big toe and femoral arterial pressure. Theseatraumatic procedures can be applied to anypatient.

Abitbol MM. Supine position in labor and associatedfetal heart rate changes.Obstet Gynecol. 1985 Apr;65(4):481-6.


Remarques :La conclusion vaut son pesant d'or, ils n'endéduisent qu'il faut éviter la positionlithotomique, mais qu'il faut mettre des capteursde mesure …

L'accouchement nondirigé, où la femmerespire et sepositionnespontanément,optmise ledéroulementphysiologique du

[1144] Traditional management of second stage laborhas come under scrutiny because of improvedunderstanding of what normally occurs when secondstage labor is allowed to proceed of its own accordwithout direction from birth attendants. When womenbear down spontaneously as they feel the urge topush, either holding their breath briefly or withshort exhalation of air, normal maternal and fetal



second stade dutravail.

physiological status is maintained and second stagelabor does not appear to be lengthened. Using avariety of maternal positions during second stagelabor can optimize physiologic functioning andincrease maternal comfort.

McKay S, Roberts J. Second stage labor: what isnormal?J Obstet Gynecol Neonatal Nurs. 1985 Mar-Apr;14(2):101-6.


Losrque la mèreaccouche assise lefoetus est mieuxoxygéné et pousseson premier cri plustôt.

[1145] Physiological evaluation of sitting deliveryposition has not been well demonstrated. Wemeasured the duration of 'the first cry occurrencetime' both in supine (n = 54) and in sitting (n =128) delivery positions. Umbilical blood gasanalysis data were obtained from 130 pregnant womenin sitting and 50 in supine delivery positions. Toelucidate the mechanism of fetal blood gasdifferences due to posture, we also analyzed thematernal arterial blood gas during delivery (n =145) and prior to labor (n = 100) in bothpositions. The first cry occurrence time wassignificantly shorter (p less than 0.01) in thesitting group. A weak negative correlation (r = -0.355, p less than 0.01) was found between theumbilical pH and the first cry occurrence time.Blood gas values for the umbilical vein and arteryin the sitting group were significantly higher inpH, Po2, BE and Sao2, and lower in Pco2. Maternalblood gas values not only at delivery but alsobefore labor did not elicit any significantdifferences between the two groups. It is suggestedthat the infants who have a high pH in theirumbilical vessels cry sooner than those with a lowpH. The cause of umbilical blood gas improvementsinduced by sitting delivery position is notdirectly due to the maternal blood gas difference,but may be mediated through other factors.

Koga S. Effects of delivery positions on the onsetof first cry and umbilical blood gas parameters.Nippon Sanka Fujinka Gakkai Zasshi. 1985Jan;37(1):107-14.


Remarque : Article en japonais[1177] A prospective study of 56 primigravidas wasperformed to assess the advantages, disadvantagesand acceptability of the upright posture during thesecond stage of labour. Twenty-seven patientslaboured in the second stage in a birthing chair,in an upright position. Twenty-one patientslaboured in bed in the recumbent position and acted



as controls. No difference could be found in thelength of second stage, ease or type of deliverybetween the 2 groups. No differences were detectedin the condition of the neonates between the 2groups. This birthing chair was found to be anacceptable mode of delivery to most of thosepatients using it.

Liddell HS, Fisher PR. The birthing chair in thesecond stage of labour.Aust N Z J Obstet Gynaecol. 1985 Feb;25(1):65-8.


La pressionextradurale est pluselevée en décubitusdorsal qu'endécubitus latéral,enceinte ou non.

[1111] Extradural pressure was measured in thelateral and the supine positions in three groups ofpatients using the extradural catheter as amanometer. The groups consisted of 20 pregnantpatients at or near term, 10 patients in the periodafter childbirth and 10 male surgical patients. Inevery patient, the extradural pressure in thesupine position was greater than that in thelateral position. The mean extradural pressures inthe lateral and the supine positions were similarin the three groups. It is suggested that thedifference between the extradural pressures in thelateral and the supine positions is physiologicaland occurs irrespective of vena caval compression.Extradural pressure changes are probably the resultof postural changes in the cerebrospinal fluid(CSF) pressure. The influence of CSF pressure onextradural pressure was confirmed further bymeasuring the extradural pressure in the proneposition in five pregnant patients.

Shah JL. Effect of posture on extradural pressure.Br J Anaesth. 1984 Dec;56(12):1373-7.


Une étude randomiséede l'influence de laposition maternellesur celle du foetuspendantl'accouchement.

[1146] The objectives of this study were to (a)determine if a safe, simple, and economic nursingprocedure--maternal posturing--would result in therotation of a fetus in the posterior or transverseposition to the optimal anterior position and (b)evaluate the relative effectiveness of a series ofmaternal postures for facilitating anterior fetalrotation. One hundred healthy women at termpregnancy were randomly assigned to four treatmentand one control posture for a 10-minute period. Attwo nurse-midwifery clinics, one certified nurse-midwife postured the subjects and one midwifemeasured the dependent variable (fetal position)with Leopold's maneuvers. Hypotheses I-IV, whichpredicted that the four rotation postures wouldhave a greater proportion of anterior fetalrotations than the control posture, were supported(p less than.000). Essentially all four postures



were effective and there was little differencebetween the treatment postures. A second posturingwas performed to determine if an additional 10minutes in a treatment posture would result in ananterior fetal position. There was a greaterproportion of anterior fetal rotations with thefour rotation postures than the control posture.The Sims posture was used as a maintenance posturefor anterior positions, and was successful whendone on the opposite side of the fetal back. Thetheoretical explication of how maternal postureseffect fetal rotation remains sound.

Andrews CM, Andrews EC. Nursing, maternal postures,and fetal position.Nurs Res. 1983 Nov-Dec;32(6):336-41.


Positionlithotomique vschaised'accouchement :durée du secondstade du travail etdes poussées pluslongue, plusd'extractionsinstrumentales,moins de pertessanguines. Aucuneinfluence sur lasanté du nouveau-né.

[1158] A randomised study of 189 deliveries wasconducted to compare performance in theconventional dorsal position with that in a birthchair. There was no significant difference in thelength of the second stage of labour, the timespent bearing down, or the need for operativedelivery. Overall blood-loss was greater amongpatients delivered in the chair but more of thisgroup had either an intact perineum or onlysuperficial damage. The condition of the neonatesin the two delivery groups was similar.

Stewart P, Hillan E, Calder AA. A randomised trialto evaluate the use of a birth chair for delivery.Lancet. 1983 Jun 11;1(8337):1296-8.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6134093[1162] The maternal half-sitting and supineposition during the second stage of fullterm laborwas compared in 100 women who, after identicalopening phases in supine position, randomlydelivered in half-sitting (50 degrees, n = 50) orsupine position (n = 50). The whole duration of thesecond stage of labor or the time spent in activepushing did not differ between the groups. Vacuumextraction was needed twice (4%) in the groupdelivering in half-sitting and six times (12%) inthe group delivering in supine position. Vaginaltear occurred in one mother in both groups. Earlydecelerations in fetal cardiotocography were seen22 times in half-sitting and 14 times in supinegroup (p less than 0.05). However, latedecelerations were seen in only one mother withhalf-sitting, as compared to five mothers withsupine position. Four infants of mothers givingbirth in supine position had 1 minute APGAR scores7 or less, whereas all infants of mothersdelivering in half-sitting position had APGAR



scores higher than 7. Subjectively the mothersliked more the half-sitting position. We concludethat a women can deliver in half-sitting positionwithout maternal or fetal risks.

Marttila M, Kajanoja P, Ylikorkala O. Maternalhalf-sitting position in the second stage of labor.J Perinat Med. 1983;11(6):286-9.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6668531[1205] Our purpose was to study the feasibility andresults of encouraging ambulation during the firststage of labor in routine obstetric practice. Six-hundred and thirty low risk mothers with intactmembranes were randomized into an ambulant and acontrol group. The results in the ambulant groupwere not better than in the control group. Ourstudy suggests that, in principle ambulation may bebeneficial, but that the concomitant changes inpractice should be different from those in ourstudy.

Hemminki E, Saarikoski S. Ambulation and delayedamniotomy in the first stage of labor.Eur J Obstet Gynecol Reprod Biol. 1983Jul;15(3):129-39.


Une baisse du rythmecardiaque et unemoins bonneoxygénation dufoetus sont observésdans 9% des casjuste après la posed'une péridurale, enassociation avec unebaisse de la tensionmaternelle et unehypertonie utérine.

[1147] Forty-six of 64 high risk labours weremanaged with continuous lumbar extraduralanalgesia. Fetal heart rate (FHR) and continuoustranscutaneous PO2 (tcPO2) measurements were madein the 64 patients. Abnormal fetal heart ratepatterns and low tcPO2 values associated with theonset of the extradural block were noted in 9% ofthese cases. A decrease in maternal arterialpressure and uterine hypertonus appeared to beresponsible, singly or in combination, for thechanges. These effects and the changes in FHR werenot seen in the 18 mothers not receiving extraduralanalgesia. The supine position was associated withslightly smaller fetal tcPO2 values than thepreferred lateral positions, with a significantworsening of the fetal tcPO2 values after inductionof the extradural block although, overall,extradural analgesia neither improved nor impairedthe fetal tcPO2.

Willcourt RJ, Paust JC, Queenan JT. Changes infetal TCPO2 values occurring during labour inassociation with lumbar extradural analgesia.Br J Anaesth. 1982 Jun;54(6):635-41.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7082525[1227] Conventional and telemetric monitoring of



labour were compared in a randomized study of 200patients to assess the effect on the pattern oflabour, outcome and attitude of the patients. Allthe telemetry patients had the option of mobility,but only 45% elected to get out of bed, and thenoften only for short periods. No clear physicalbenefits accrued from voluntary mobility. Ambulantpatients who had spontaneous deliveries had alonger second stage and more of their babies wereslow to establish regular respiration. Quantitativesubjective assessments of pain, anxiety and comfortwere made. Primigravidae with telemetric monitoringwho chose to get out of bed had higher pain scoresthan primigravidae monitored conventionally, butanxiety scores were highest among primigravidaewith telemetry who elected to stay in bed. Therewas a significant bias towards increased anxiety inthe lower social classes. Primigravidae gained morereassurance from monitoring than did multigravidae,but there were no differences resulting fromwhether or not the recording apparatus was withinthe patients' view. Multigravidae who hadexperienced both forms of monitoring preferredtelemetry because they felt less restricted andless anxious.

Calvert JP, Newcombe RG, Hibbard BM. An assessmentof radiotelemetry in the monitoring of labour.Br J Obstet Gynaecol. 1982 Apr;89(4):285-91.


Une comparaison del'efficacité descontractions et despréférences desfemmes en alternantles position detravail (premierstade) assise et endécubitus latéral.

[1148] The influence of maternal position duringlabor on comfort and uterine efficiency was studiedby contrasting the influence of sitting in a chairwith lying on the side during the first stage oflabor. Nineteen primigravidas alternated betweenthese two positions at 30 minute intervals for aslong as this was possible during their labors.There was a significant difference in theirpreference to sit up during early labor (less than6 cm dilation) and lie on their side during latelabor (greater than 6 cm dilation). Uterineefficiency, however, was significantly less (p lessthan 0.05) in early labor in the sitting positionthan on the side. After labor was well established,ie after 6 cm dilation, the efficiency of uterinecontractions to dilate the cervix was notsignificantly different between the 2 positionsalthough it was less in the sitting position. Thelateral recumbent position was accompanied by moreefficient labor and was preferred by most women inlate labor. Localization of pain and fetal positionalso seem to be associated with maternal positionpreference, and both factors require furtherinvestigation.

Roberts J, Malasanos L, Mendez-Bauer C. Maternal



positions in labor: analysis in relation to comfortand efficiency.Birth Defects Orig Artic Ser. 1981;17(6):97-128.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7326378[1204] Published reports imply that intrapartumambulation may improve labor. This suggests thepossible efficacy of ambulation in labors requiringaugmentation, provided that adequate monitoringsurveillance is maintained. Fourteen patients whofailed to progress in active-phase labor, and whorequired augmentation for "inadequate" contractionswere randomized into ambulation (eight) andoxytocin (six) groups. Internal fetal monitoringwas used in all patients for 30 minute baseline and2 hour study periods, with two-channel telemetryused in ambulating patients. Oxytocin wasadministered by infusion pump. Study parametersincluded changes in cervical dilation and station,contraction frequency, intensity and baselinetonus, and uterine activity. Labor progress wasslightly but not significantly better in theambulatory group. A mean increase in uterineactivity units (UAU) in the ambulatory group wasimmediate to ranges not reached in the oxytocingroup for 2 hours. Increase in Montevideo units wasslightly greater in the ambulatory group during thefirst hour, but was exceeded by the oxytocin groupduring the second hour. These initial observationsseem to indicate that, in terms of labor progressand initial effects on uterine activity, ambulationis as effective as oxytocin for the enhancement oflabor and warrants further investigation.

Read JA, Miller FC, Paul RH. Randomized trial ofambulation versus oxytocin for labor enhancement: apreliminary report.Am J Obstet Gynecol. 1981 Mar 15;139(6):669-72.


Les positionslatérales etverticales sontpositives pour letravail. Les femmesdoivent êtreencouragées àchoisir leurposition.

[1117] La position traditionelle sur le dos pendantle travail et la naissance est une innovationrelativement récente and des désavantages distinctsont été cités. Les positions latérales et deboutaméliorent la qualité des contractions utérines. Deplus, la position debout entraine un travail pluscours et plus confortable que les autres positions.Les femmes doivent être éduquées aux bénéfice despositions alternatives et à la mobilité et doiventêtre assistöes dans leur choix de la position laplus physiologique pendant l'accouchement.

McKay SR. Maternal position during labor and birth:a reassessment.JOGN Nurs. 1980. Sep-Oct;9(5):288-91.



http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=6904654&dopt=Citation[1228] This study included 369 normal term labors.In 145 cases the women were sitting, standing orwalking at will during the first stage, whereas 224remained lying in bed during the whole labor. Whenthe mother remains in the 'vertical position duringthe first stage of labor (1) the physiologicaltiming of the spontaneous rupture of membranes isnot altered, (2) duration of the first stage isshortened in 25%--this shortening may reach 34% inthe nulliparas, (3) cephalic molding is notincreased, (4) the incidence of forceps deliverydiminishes and (5) perinatal morbimortality is notincreased.

Diaz AG, Schwarcz R, Fescina R, Caldeyro-Barcia R.Vertical position during the first stage of thecourse of labor, and neonatal outcome.Eur J Obstet Gynecol Reprod Biol. 1980 Sep;11(1):1-7.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7193605[1231] A prospective study of 300 consecutivedeliveries has been made to assess the benefits andacceptability of ambulation during spontaneouslabour. Ambulation during the first stage occurredin 48 patients with 55 non-ambulant patients actingas controls. No difference in the length of firstor second stage, incidence of fetal distress ormode of delivery was observed. In spite of the lackof apparent advantage to the fetal condition,ambulation was acceptable to both patients andnursing staff and should not be discouraged.

Williams RM, Thom MH, Studd JW. A study of thebenefits and acceptability of ambulation inspontaneous labour.Br J Obstet Gynaecol. 1980 Feb;87(2):122-6.


Histoire despositionsd'accouchementdepuis 1900.

[1112] The basis of maternity care practicesrelated to maternal position for childbirth isanalyzed historically in a review of the Americanperiodical nursing literature from the early 1900'sto the present and of contemporary maternitynursing texts. The factors of 1) concomitantobstetrical practices, 2) the prerogative of thephysician, and 3) the evolving and predominantlysupportive role of the nurse are identified as themajor influences on these nursing practices.Historical aspects of the development of thecurrent role of the nurse in maternity care areidentified. While nurses are currently questioningcare practices related to the positions of womenfor childbirth and offering more explicit



rationale, the need for research related tofeatures of physical care and a more assertiveprofessional role for nurses is emphasized.

Roberts JE. Maternal positions for childbirth: ahistorical review of nursing care practices.JOGN Nurs. 1979 Jan-Feb;8(1):24-32.


Pendant lescontractions,l'apport sanguin àla moitié inférieuredu corps tend àdiminuer. En outrel'oxygénation estmeilleure endécubitus latéralqu'en positionlithotomique.

[1149] The authors investigated changes in bloodflow to the lower half of the body of pregnantwomen in supine and lateral positions toward theend of pregnancy and during uterine contractions.Electroplethysmographic recordings taken to thatend from the legs of probands revealed significantdecline in blood supply during uterinecontractions. The changes recorded werestatistically significant. In some cases, no changeat all was caused by uterine contraction orpositioning. Uterine activity was recorded byintra-uterine pressure registration. With theparturient in lateral position blood flows underreview proved to be better than in supine position.

Hadjiev A, Iordanov G. Changes in maternalcirculation provoked by uterine contractions.Zentralbl Gynakol. 1979;101(17):1091-6.


Etude randomiséecontrôlée comparantl'accouchement enposition verticaleet en décubituslatéral. Lesconclusions sont debien peu de valeureu égard a leur trèsfaible statistiqueet au fait que lesaccouchementsétaient déclenchés(donc conditionsphysiologiques nonrespectées).

[1181] The claim that an upright maternal postureduring labour improves the efficiency of the uterusto the benefit of both mother and fetus has beeninvestigated in a randomised prospective study. 40patients undergoing induction of labour wereallocated to a recumbent group or an upright group.No differences were found between the groups in thelength of labour, mode of delivery, requirements ofoxytocic and analgesic drugs, or fetal and neonatalcondition. Our data do not support calls to changeconventional intrapartum nursing attitudes.

McManus TJ, Calder AA. Upright posture and theefficiency of labour.Lancet. 1978 Jan 14;1(8055):72-4.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=74569[1203] n a randomised prospective study of 68 womenin spontaneous labour half were allocated to anambulant group and half to a recumbent group. Theduration of labour was significantly shorter, theneed for analgesia significantly less, and theincidence of fetal heart abnormalitiessignificantly smaller in the ambulant group than inthe recumbent group. Apgar scores at one and fiveminutes were also significantly greater in the



ambulant group. More patients in the recumbentgroup required augmentations with oxytocic drugs.There was no statistically significant differencein the third stage loss in the two groups.Ambulation in labour should be encouraged: it maybring human benefits while allowing the advantagesof hospital supervision.

Flynn AM, Kelly J, Hollins G, Lynch PF. Ambulationin labour.Br Med J. 1978 Aug 26;2(6137):591-3.


La position deboutpendant le travaildevrait êtreutilisée plusfréquellement enobstétrique.

[1114] The aim of this paper has been to comparethe uterine contractility, pain produced bycontractions and comfort of the patients betweenstanding and supine position. The study has beenperformed in twenty normal nulliparae who werechanged from supine to standing position andviceversa at intervals of approximately thirtyminutes. Intrauterine pressure and fetal heart ratewere continuously monitored. Cervial dilatation wasevaluated every thirty minutes. No medication wasgiven to the patients. They were asked to assessthe pain produced by uterine contractions in eachone of both positions and which was the morecomfortable. It has been found: 1. That theintensity of contractions was significantly higherin fifteen out of the twenty patients in standingposition. 2. Frequency of contractions diminishedsignificantly in one third of the patients. 3.Uterine activity increased significantly in half ofthem. 4. Consistently, less pain accompanieduterine contractions in standing position. 5.Patients reported more comfort in this position.The average duration of labor was 3 hrs 55 min.This duration is short, compared with standardclinical experience and with published data. Nocomplications occurred, by the use of standingposition during labor, on the mother or fetus. Thephysiological mechanisms responsible for the abovementioned effects of standing position are unknown.It is condluced that there are no clear argumentsagainst the use of standing position during laborand that this position should be used morefrequently in clinical obstetrics, providedobstetrical conditions are similar to thosereported in this paper.

Mendez-Bauer C, Arroyo J, Garcia Ramos C, MenendezA, Lavilla M, Izquierdo F, Villa Elizaga I,Zamarriego J. Effects of standing position onspontaneous uterine contractility and other aspectsof labor.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1185484&dopt=Citation



[1200] Upper and lower limb blood flow was measuredin 4 full-term pregnant women in the left lateraland supine positions before and after epiduralblock. Radial artery mean blood pressure wasrecorded in 6 full term pregnant women under thesame conditions. Before epidural block there was amuch greater reduction in lower limb blood flow(39-1%) than in upper limb blood flow (13-5%) whenwomen moved from the lateral to the supineposition; this was probably the result of aorticcompression. Mean radial artery pressure increasedslightly by 4-6% due to maternal overcompensationin the upper part of the body. After epiduralblock, patients in the lateral position had a meanrise in lower limb blood flow of 25% and areduction in upper limb blood flow of 37-2%. Themean arterial pressure remained unchanged. In thesupine position there was no further reduction ofupper limb blood flow; this was accompanied onaverage by a 9% fall in mean radial arterialpressure indicating decompensation in the mother.The leg blood flow fell less, 26-9% than beforeepidural block. In the supine position, a greaterflow to the legs, associated with a decreased meanarterial pressure, would be expected to lead to adiminution in placental perfusion, which is theprobable mechanism for foetal decompensation.Therefore the supine position should be avoidedwith an epidural block. In other patients it wouldbe wise not to rely upon maternal compensatorymechanisms.

Weaver JB, Pearson JF, Rosen M. Posture andepidural block in pregnant women at term. Effectson arterial blood pressure and limb blood flow.Anaesthesia. 1975 Nov;30(6):752-6.


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