Squatting position in the second stage of labor: A systematic review and meta-analysis

OBJECTIVES: The influence of squatting during delivery on maternal and fetal outcomes remains unclear. We performed a systematic review and meta-analysis to evaluate the benefits and risks of adopting a squatting position during the second stage of labor.

STUDY DESIGN: Search Strategy: A systematic search in the three major electronic databases (CENTRAL, PubMed and Embase) was performed, from their respective inception dates to the 14th of December 2019, using 'squatting', and a combination of keywords to identify delivery. Eligibility criteria: Randomized controlled trials comparing squatting position to any supine position during the second stage of labor.

STATISTICAL ANALYSES: Risk ratio for dichotomous outcomes, mean difference for continuous outcomes, with 95 % confidence intervals. Fixed-effects meta-analysis (Mantel-Haenszel method) or random-effects model (inverse variance method), for low and high heterogeneity between trials, respectively. PROSPERO Registration number: CRD42018093244 RESULTS: Seven randomized controlled trials (n = 1219) were included. Three studies were assessed as low risk of bias, three others as moderate and one study as high risk of bias. The main limitation is the lack of reporting on the methods to achieve randomization and concealment of allocation in most of the studies. There was no difference in the duration of the second stage of labor (mean -11.09 min; 95 %CI -38.85 to 16.68). In the squatting group, the risk of caesarean section was increased (RR 2.26, 95 %CI 1.07-4.80) and the risk of instrumental delivery was decreased (RR 0.60, 95 %CI 0.45-0.81), which results in a similar probability of spontaneous delivery. There were no differences regarding the other maternal and fetal outcomes.

CONCLUSIONS: The available evidence does not show the squatting position during childbirth to be beneficial. As there is no evidence for or against squatting, women should be able to choose the position they prefer.