Positions Second Stage. Ayuda por favor.

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Seguramente tengas este documento, ahi te va, son las evidence based guidelines del RCM, espero que al menos las referencias puede que te sirvan.....

Positions for Labour and Birth Practice Points

There are significant advantages to assuming an upright position in labour (MIDIRS and the NHS Centre for Reviews and Dissemination 2003) and birth. However, lying down continues to remain the most common position.

Women often “‘choose” to do what is expected of them, and the most common image of the labouring woman is “on the bed”. Midwives therefore need to be proactive in demonstrating and encouraging different positions in labour.

No harmful effects have been associated with walking during labour, and women should be encouraged to do this if they wish (Bloom et al. 1998).

The environment is key to freedom of movement. There should be a variety of furniture and props available in the room that encourage women to try different positions.

The use of electronic fetal monitoring, intravenous infusions and different methods of analgesia may affect a woman’s mobility and use of postural change during labour (Spiby et al. 2003). Women need to be aware of this in order for them to make an informed choice about their use (MIDIRS and he NHS Centre for Review and Dissemination 2003).

Use of postural coping strategies during the first stage of labour is associated with providing some pain relief and helping a woman to cope with pain (Spiby et al. 2003).

Use of upright positions for the second stage of labour confers several benefits including a shorter second stage, fewer instrumental births, fewer episiotomies although estimated blood loss is greater (Gupta and Hofmeyr 2004).

Use of the lateral position for birth appears to protect the perineum (Shorten et al. 2002).

Squatting using a birthing chair has been reported as a predisposing factor for third and fourth degree tears (Jander and Lyrenas 2001).

There are several theoretical physiological advantages for being upright during labour. These include gravity; reduced risk of aorto-caval compression; better alignment of the fetus; more efficient contractions and increased pelvic outlet in squatting and kneeling positions (MIDIRS and the NHS Centre for Reviews and Dissemination 2003).
Upright positions in the first stage are those that avoid lying flat, and may include walking around. Upright positions in the second stage include sitting (more than 45 degrees from the horizontal), squatting or kneeling, and being on hands and knees. Recumbent positions include supine, lateral, lithotomy, and semi-recumbent with wedges (MIDIRS and the NHS Centre for Reviews and Dissemination 2003).
A recent large trial investigated the effects of walking during labour and found no differences in length of first stage, use of oxytocin, analgesic use, or instrumental or operative births between women allocated to walking and those who were allocated to usual care in bed (Bloom et al. 1998). The population included were predominantly Hispanic and black women, and there were elements of labour care that appear different from UK midwifery practice. The duration of walking was an average of 56 minutes, and a significant proportion (reported as 22%) of women allocated to walking did not do so. Earlier studies of walking in labour had conflicting findings related to duration of first stage of labour as being shorter or no different. One commentator observes that there appears to be no ill effect from walking, but that further studies are urgently needed as to whether walking is an effective intervention for slow cervical dilatation (Goer 1999).
An upright position in the first stage can mean less severe pain (Hemminki and Saarikoski 1983), shorter first stage (Roberts et al. 1983) and less use of narcotics and epidurals (Williams et al. 1980). The use of position changes as a coping strategy for labour is associated with providing some pain relief and helping to cope with pain (Spiby et al. 2003).
In some studies it was observed that women changed positions frequently in the first half of the first stage (Gardosi et al. 1989). Gould reported, using concept analysis, that movement was a vital component in normal labour (2000). Some women preferred to recline in the bed as labour progressed (Hemminki and Saarikoski 1983; Roberts et al. 1983).
A systematic review has compared use of any upright or lateral position with supine or lithotomy positions in the second stage (Gupta and Hofmeyr 2004). This review shows that women’s being upright results in a shorter second stage; fewer assisted births and episiotomies; more second degree perineal tears; more women with a blood loss estimated as over 500ml, fewer reports of severe pain and fewer fetal heart rate abnormalities. The upright position during the second stage was achieved in a number of ways: by the woman squatting or through use of equipment such as birth stools, chairs or cushions. For that reason, and due to the variation in methodological quality across the trials, the results should be interpreted with caution. However, the reviewers suggest that, in the absence of ill-effect (apart from increased blood loss) women can be encouraged to adopt positions of comfort during the second stage of labour.
This review also examines the effects and experiences of using a birth stool with the supine position, the lateral and supine positions; use of a birth cushion with supine or lithotomy positions and birth chair compared with supine or lithotomy position (Gupta and Hofmeyr 2004).
Use of a birth stool results in fewer episiotomies, more second degree tears, a higher incidence of blood loss estimated to be over 500 mls; fewer reports of severe pain at birth and (in the only trial that reported it) fewer fetal heart rate abnormalities than the supine posture (Gupta and Hofmeyr 2004). Comparison of the lateral and supine positions found no differences for length of second stage, episiotomies and assisted births although numbers were small. Use of the birth cushion resulted in shorter second stages of labour, less assisted births, no difference in episiotomies and blood loss estimated to be over 500ml and less second degree tears when compared with the second stage spent in supine or lithotomy positions. Comparisons of the birth chair with the supine or lithotomy position found no difference in length of second stage, fewer episiotomies, more second degree tears and more women experiencing blood loss estimated at greater than 500ml.
In a review of 2891 births from New South Wales, researchers used multiple regression analysis to examine associations between birth position, accoucheur and perineal trauma (Shorten et al. 2002). A protective effect on perineal integrity was identified from use of the lateral position for birth. In contrast, use of the squatting position was associated with the lowest proportion of intact perineum, particularly amongst women having their first baby. Other birth positions including standing, kneeling and all fours were not associated with increased benefit compared to the semi-recumbent position. Squatting using a low birthing chair has been implicated as a predisposing factor for third and fourth degree tears in a case control study of births in Sweden (Jander and Lyrenas 2001).
On the whole women will ‘”choose” to do what they think is expected of them and they are usually informed by the most common image of the labouring women as lying down. Midwives will need to be proactive in demonstrating and encouraging different positions. The labour environment is key to women’s ability to try different positions (MIDIRS and The NHS Centre for Reviews and Dissemination 2003). There should be appropriate furniture and props readily available: bean bags, mattresses, chairs and birth balls. A useful account of the introduction of a birth ball into midwifery practice is reported by Shallow (2003).
The use of electronic fetal monitoring, intravenous infusions and different methods of analgesia will all affect women’s mobility. Women need to be aware of this in order for them to make an informed choice (MIDIRS and the NHS Centre for Reviews and Dissemination 2003). These procedures may also interfere with use of postural coping strategies in labour (Spiby et al. 2003). Support should then be given to continue or resume use of postural strategies if they have been interrupted by care procedures.

References
Bloom SL, McIntire DD, Kelly MA et al. (1998) Lack of effect of walking on labor and delivery. New England Journal of Medicine 339: 76-79 Back
Gardosi J, Hutson N, B-Lynch C (1989) Randomised controlled trial of squatting in the second stage of labour. The Lancet 8654: 74-77 Back
Goer H (1999) Does walking enhance labor progress? Birth 26: 127-129 Back
Gould D (2000) Normal labour: a concept analysis. Journal of Advanced Nursing 31: 418-427 Back
Gupta JK, Hofmeyr GJ (2004) Position for women during second stage of labour (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley and Sons, Ltd. Back
Hemminki E, Saarikoski S (1983) Ambulation and delayed amniotomy in the first stage of labour. European Journal of Obstetrics, Gynaecology and Reproductive Biology 15: 129-139 Back
Jander C, Lyrenas S (2001) Third and fourth degree perineal tears. Predictor factors in a referral hospital. Acta Obstetricia et Gynecologica Scandinavica 80: 229-234 Back
MIDIRS and The NHS Centre for Reviews and Dissemination (2003) Positions in labour and delivery. Informed choice for professionals leaflet Back
Roberts JE, Mendez-Bauer C, Wodell DA (1983) The effects of maternal position on uterine contractility and efficiency. Birth 10: 243-249 Back
Shallow H (2003) My rolling programme. The birth ball: ten years experience of using the physiotherapy ball for labouring women. MIDIRS Midwifery Digest 13: 28-30 Back
Shorten A, Donsante J, Shorten B (2002) Birth position, accoucheur, and perineal outcomes: informing women about choices for vaginal birth. Birth 29: 18-27 Back
Spiby H, Slade P, Escott D, Henderson B, Fraser RB (2003) Selected coping strategies in labour: an investigation of women’s experiences. Birth 30: 189-194 Back
Williams RM, Thorn MH, Studd JWW (1980) A Study of the benefits and acceptability of ambulation in spontaneous labour. British Journal of Obstetrics and Gynaecology 87: 122-126 Back