A influência de métodos não farmacológicos na duração do parto: uma revisão sistemática

Gregolis, Thais Blaya Leite; Santos, Sabrina da Silva; Silva, Ilce Ferreira da; Bessa, Andréa Ramos da Silva

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Sumário

ARTICLE REVIEW • Ciênc. saúde coletiva 29 (06) • Jun 2024 • https://doi.org/10.1590/1413-81232024296.19032022 copiar

A influência de métodos não farmacológicos na duração do parto: uma revisão sistemática

Autoria SCIMAGO INSTITUTIONS RANKINGS

Resumo

O objetivo do artigo é verificar a influência dos MNFs na duração do processo de parto. Realizou-se uma revisão sistemática nas bases de dados MEDLINE, Web of Science e LILACS, por meio da combinação de termos que contemple a temática abordada, no período de 1996 a 2021/abril. Utilizou-se para coleta de dados a planilha Excel para extração de informações referentes a cada artigo selecionado, por sua vez, a análise dos dados compreendeu a avaliação e classificação da qualidade, confiabilidade e risco de viés, assim, utilizou-se como ferramentas: Cochrane RoB 2, Checklist e Escala de Newcastle-Ottawa. Reduziram o tempo de trabalho de parto banho morno, caminhada, exercícios com bola de parto, técnicas respiratórias, decúbito dorsal, acupuntura, acupressão e parto na água. Enquanto empurrões espontâneos, massagem e banho de imersão prolongaram o trabalho de parto. Os métodos não farmacológicos capazes de reduzir a duração do trabalho de parto foram banho de chuveiro quente/morno, caminhada, exercícios com bola de parto, técnicas de respiração, mobilidade materna, posição dorsal, acupuntura, acupressão e parto na água, também encurtaram o tempo de parto técnicas aplicadas associadas como banho quente/morno, exercícios com bola e massagem lombossacral, assim como banho de imersão, exercícios com bola, aromaterapia, posturas verticais e mobilidade materna com posturas verticais alternadas.

Palavras-chave:
Métodos; Parto; Parto humanizado; Tempo

Study	Year	Country	Study design	Method assessed
Bomfim-Hyppólito, 1998¹⁶16 Bomfim-Hyppólito S. Influence of the position of the mother at delivery over some maternal and neonatal outcomes. Int J Gynecol Obstetr 1998; 21(63):S67-S73.	1994	Brazil (Fortaleza)	Experimental	Semi-sitting position (60º trunk inclination) during expulsion stage
Eckert et al., 2001¹⁷17 Eckert K, Turnbull D, MacLennan A. Immersion in water in the first stage of labor: a randomized controlled trial. Birth 2001; 28(2):84-93.	1995	Australia	Experimental	Immersion bath in first stage of labor.
Schröcksnadel et al., 2003¹⁸18 Schröcksnadel H, Kunczicky V, Meier J, Brezinka C, Oberaigner W. Water Birth: experience at a university clinic and a district hospital in Austria. Gynakol Geburtshilfliche Rundsch 2003; 43(1):7-11.	1998	Austria	Case-control	Water birth.
Almeida et al., 2005¹⁹19 Almeida NAM, Sousa JT, Bachion MM, Silveira NA. Utilização de técnicas de respiração e relaxamento para alívio de dor e ansiedade no processo de parturição. Rev Lat Am Enferm 2005; 13(1):52-58.	2000	Brazil (Goiânia)	Experimental	Breathing techniques associated with relaxation techniques.
Bio et al., 2006⁷7 Bio E, Bittar RE, Zugaib M. Influência da mobilidade materna na duração da fase ativa do trabalho de parto. Rev Bras Ginecol Obstetr 2006; 28(11):671-679.	2003	Brazil (São Paulo)	Experimental	Keep moving and switching to vertical positions during labor and delivery.
Silva and Oliveira, 2006²⁰20 Silva FMB, Oliveira SMJV. O efeito do banho de imersão na duração do trabalho de parto. Rev Esc Enferm USP 2006; 40(1):57-63.	2002	Brazil (São Paulo)	Experimental	Immersion bath for 40-60 minutes.
Gaudernack et al., 2006²¹21 Gaudernack LC, Forbord S, Hole E. Acupuncture administered after spontaneous rupture of membranes at term significantly reduces the length of birth and use of oxytocin: a randomized controlled trial. Acta Obstet Gynecol Scand 2006; 85(11):1348-1353.	2003	Norway	Experimental	Acupuncture.
Zanetti-Daellenbach et al., 2007²²22 Zanetti-Daellenbach RA, Tschudin S, Zhong XY, Holzgreve W, Lapaire O, Hösli I. Maternal and neonatal infections and obstetrical outcome in water birth. Eur J Obstet Gynecol Reprod Biol 2007; 134(1):37-43.	1998	Switzerland	Cohort	Water birth after immersion bath for time desired by parturient.
Mamede et al., 2007²³23 Mamede FV, Almeida AM, Souza L, Mamede MV. A dor durante o trabalho de parto: o efeito da deambulação. Rev Lat Am Enfermagem 2007; 15(6):1157-1162.	2004	Brazil (São Paulo)	Quasi-experimental	Walking during active stage of labor.
Gau et al., 2011²⁴24 Gau M-L, Chang C-Y, Tian S-H, Lin K-C. Effects of birth ball exercise on pain and self-efficacy during childbirth: a randomised controlled trial in Taiwan. Midwifery 2011; 27(6):e293-300.	2008	Taiwan	Experimental	Birth ball exercise.
Cortes et al., 2011²⁵25 Cortes E, Basra R, Kelleher CJ. Waterbirth and pelvic floor injury: a retrospective study and postal survey using ICIQ modular long form questionnaires. Eur J Obstet Gynecol Reprod Biol 2011; 155(1):27-30.	2011	UK	Population-based cohort	Water birth.
Gallo et al., 2013²⁶26 Gallo RBS, Santana LS, Ferreira CHJ, Marcolin AC, Polineto OB, Duarte G, Quintana SM. Massage reduced severity of pain during labour: a randomised trial. J Physiother 2013; 59(2):109-116.	2009	Brazil (Ribeirão Preto)	Experimental	Massage during dilation period and uterine contractions for 30 mins.
Liu et al., 2014²⁷27 Liu Y, Liu Y, Huang X, Du C, Peng J, Huang P, Zhang J. A comparison of maternal and neonatal outcomes between water immersion during labor and conventional labor and delivery. BMC Pregnancy Childbirth 2014; 14:160.	2009	China	Experimental	Immersion bath in active stage of labor.
Mafetoni and Shimo, 2015²⁸28 Mafetoni RR, Shimo AKK. Efeitos da acupressão na evolução do parto e taxa de cesárea: ensaio clínico randomizado. Rev Saude Publica 2015; 49:9.	2013	Brasil (Campinas)	Experimental	Acupressure at point BP6.
Desseauve et al., 2016²⁹29 Desseauve D, Gachon B, Bertherat P, Fradet L, Lacouture P, Pierre F. Dans quelle position les femmes accouchent-elles en 2015? Résultats d'une étude prospective régionale multicentrique. Gynécologie Obstétrique Fertil 2016; 44(10):548-556.	2015	France	Cross-sectional	Dorsal decubitus during labor and delivery, change in position during labor, dorsal decubitus in expulsion stage.
Vaziri et al., 2016³⁰30 Vaziri F, Arzhe A, Asadi N, Pourahmad S, Moshfeghy Z. Spontaneous pushing in lateral position versus valsalva maneuver during second stage of labor on maternal and fetal outcomes: a randomized clinical trial. Iran Red Crescent Med J 2016; 18(10):e29279.	2014	Iran	Experimental	Spontaneous pushing in lateral position.
Koyucu and Demirci, 2017³¹31 Koyucu RG, Demirci N. Effects of pushing techniques during the second stage of labor: A randomized controlled trial. Taiwan J Obstet Gynecol 2017; 56(5):606-612.	2013	Turkey	Experimental	Spontaneous pushing.
Cicek and Basar, 2017³²32 Cicek S, Basar F. The effects of breathing techniques training on the duration of labor and anxiety levels of pregnant women. Complement Ther Clin Pract 2017; 29:213-219.	2016	Turkey	Experimental	Lamaze breathing technique.
Makvandi et al., 2018³³33 Makvandi S, Mirzaiinajmabadi K, Mirteimoori M, Esmaily H. Effect of normal physiologic childbirth program in mother-friendly hospitals on duration of labor. Electron J Gen Med 2018; 15(3):em21.	2016	Iran	Quasi-experimental	Combination of immersion bath, birth ball exercise, aromatherapy with lavender.
Gallo et al., 2018⁸8 Gallo RBS, Santana LS, Marcolin AC, Duarte G, Quintana SM. Sequential application of non-pharmacological interventions reduces the severity of labour pain, delays use of pharmacological analgesia, and improves some obstetric outcomes: a randomised trial. J Physiother 2018; 64(1):33-40.	2011	Brazil (Ribeirão Preto)	Experimental	Pelvic movement exercises on Swiss ball, 40-min massage, 40-min hot/warm shower.
Ulfsdottir et al., 2018³⁴34 Ulfsdottir H, Saltvedt S, Georgsson S. Waterbirth in Sweden: a comparative study. Acta Obstet Gynecol Scand 2018; 97(3):341-348.	2014	Sweden	Cohort	Water birth.
Maddady et al., 2018³⁵35 Maddady S, Mohammad-Alizadeh S, Shafaei S, Mirghafourvand M. Comparing the effects of hot shower and intravenous injection of hyoscine on the pain intensity and duration of active phase of labour in nulliparous women. Iranian J Obstetr Gynecol Infertility 2018; 12(8):QC07-QC11.	2015	Iran	Experimental	Hot / warm shower.
Mafetoni et al., 2018³⁶36 Mafetoni RR, Jacob LMS, Jorge HMF, Shimo AKK. Efeitos da auriculoterapia no tempo de trabalho de parto e taxa de cesárea: ensaio clínico randomizado. REME 2018; 22:e1139.	2015	Brazil (Campinas)	Experimental	Auriculotherapy.
Cavalcanti et al., 2019³⁷37 Cavalcanti ACV, Henrique AJ, Brasil CM, Gabrielloni MC, Barbieri M. Terapias complementares no trabalho de parto: ensaio clínico randomizado. Rev Gaucha Enferm 2019; 40:e20190026.	2013	Brazil (São Paulo)	Experimental	Hot / warm shower and exercises with Swiss ball, alone and in combination.
Neiman et al., 2020³⁸38 Neiman E, Austin E, Tan A, Anderson CM, Chipps E. Outcomes of waterbirth in a US Hospital-Based Midwifery practice: a retrospective cohort study of water immersion during labor and birth. J Midwifery Womens Health 2020; 65(2):216-223.	2016	USA	Cohort	Immersion bath and waterbirth.

Study	Intervention	Sample		Effect	Duration (minutes)		Statistics	Quality
		With NPMs	Without NPMs		With NPMs	Without NPMs
Hot/warm shower
Maddady et al., 2018³⁵35 Maddady S, Mohammad-Alizadeh S, Shafaei S, Mirghafourvand M. Comparing the effects of hot shower and intravenous injection of hyoscine on the pain intensity and duration of active phase of labour in nulliparous women. Iranian J Obstetr Gynecol Infertility 2018; 12(8):QC07-QC11.	Hot / warm shower	50	49	Reduction	Active stage: 221.2	Active stage: 312.6	Mean Difference -110.7; 95%CI: 169.5; -51.8	Low risk of bias¹²12 Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Systematic reviews of effectiveness. In: Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, editors. JBI Manual for Evidence Synthesis [Internet]. 2020 [cited 2023 jul 8]. Available from; https://synthesismanual.jbi.global. https://synthesismanual.jbi.global...
Immersion bath
Silva and Oliveira, 2006²⁰20 Silva FMB, Oliveira SMJV. O efeito do banho de imersão na duração do trabalho de parto. Rev Esc Enferm USP 2006; 40(1):57-63.	Immersion bath for 40 to 60 minutes	54	54	No effect	6-10 cm dilation: 250.9	6-10 cm dilation: 260.4	p=0.89	Low risk of bias¹²12 Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Systematic reviews of effectiveness. In: Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, editors. JBI Manual for Evidence Synthesis [Internet]. 2020 [cited 2023 jul 8]. Available from; https://synthesismanual.jbi.global. https://synthesismanual.jbi.global...
Neiman et al., 2020³⁸38 Neiman E, Austin E, Tan A, Anderson CM, Chipps E. Outcomes of waterbirth in a US Hospital-Based Midwifery practice: a retrospective cohort study of water immersion during labor and birth. J Midwifery Womens Health 2020; 65(2):216-223.	Immersion bath	61	111	Nulliparous No effect Increase Multiparous No effect No effect	Nulliparous Active stage: 764.7 Expulsion stage: 88.4 Multiparous Active stage: 469.3 Expulsion stage: 20.6	Nulliparous Active stage: 757.8 Expulsion stage: 79.7 Multiparous Active stage: 401.9 Expulsion stage: 16.8	Nulliparous p=0.13 p=0.03 Multiparous p=0.59 p=0.08	Good quality¹⁴14 Wells GA, Shea B, O'Connell D, Peterson J, Welch V, Losos M, Tugwell P. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses [Internet]. The Ottawa Hospital, Our Research; 2021 [cited 2023 jul 8]. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp.
Liu et al., 2014²⁷27 Liu Y, Liu Y, Huang X, Du C, Peng J, Huang P, Zhang J. A comparison of maternal and neonatal outcomes between water immersion during labor and conventional labor and delivery. BMC Pregnancy Childbirth 2014; 14:160.	Immersion bath in first stage of labor	33	47	No effect No effect	Active stage: 596.55 Expulsion stage: 58.79	Active stage: 552.30 Expulsion stage: 56.04	p=0.43 p=0.72	Some concerns¹³13 Palmeri V, Colamesta V, La Torre G. Evaluation of methodological quality of studies. Senses Sci 2016; 3(3):235-224.
Eckert et al., 2001¹⁷17 Eckert K, Turnbull D, MacLennan A. Immersion in water in the first stage of labor: a randomized controlled trial. Birth 2001; 28(2):84-93.	Immersion bath in first stage of labor	137	137	No effect No effect	Active stage: 404.23 Expulsion stage: 64.94	Active stage: 407.21 Expulsion stage: 68.80	p=0.89 p=0.65	High risk of bias¹²12 Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Systematic reviews of effectiveness. In: Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, editors. JBI Manual for Evidence Synthesis [Internet]. 2020 [cited 2023 jul 8]. Available from; https://synthesismanual.jbi.global. https://synthesismanual.jbi.global...
Walking
Mamede et al., 2007²³23 Mamede FV, Almeida AM, Souza L, Mamede MV. A dor durante o trabalho de parto: o efeito da deambulação. Rev Lat Am Enfermagem 2007; 15(6):1157-1162.	Walking	75	-	Reduction	Active stage: 22; 10 and 6 minutes shorter for every 100 meters walked at 1^st, 2^nd or 3^rd hour, respectively	Linear regression		Low risk of bias¹³13 Palmeri V, Colamesta V, La Torre G. Evaluation of methodological quality of studies. Senses Sci 2016; 3(3):235-224.
Breathing techniques
Cicek and Basar, 2017³²32 Cicek S, Basar F. The effects of breathing techniques training on the duration of labor and anxiety levels of pregnant women. Complement Ther Clin Pract 2017; 29:213-219.	Lamaze breathing technique	35	35	Reduction Reduction No effect No effect	Latent stage: 403.71 Active stage: 174.00 Transition stage: 110.71 Expulsion stage: 19.11	Latent stage: 658.71 Active stage: 264.57 Transition stage: 101.42 Expulsion stage: 24.48	p<0.001 p=0.01 p=0.28 p=0.14	Some concerns¹²12 Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Systematic reviews of effectiveness. In: Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, editors. JBI Manual for Evidence Synthesis [Internet]. 2020 [cited 2023 jul 8]. Available from; https://synthesismanual.jbi.global. https://synthesismanual.jbi.global...
Ball exercises
Gau et al., 2011²⁴24 Gau M-L, Chang C-Y, Tian S-H, Lin K-C. Effects of birth ball exercise on pain and self-efficacy during childbirth: a randomised controlled trial in Taiwan. Midwifery 2011; 27(6):e293-300.	Birth ball exercises	48	39	Reduction No effect	Active stage: 380 Expulsion stage: 38.48	Active stage: 485.4 Expulsion stage: 41.3	p=0.04 p=0.59	Some concerns¹²12 Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Systematic reviews of effectiveness. In: Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, editors. JBI Manual for Evidence Synthesis [Internet]. 2020 [cited 2023 jul 8]. Available from; https://synthesismanual.jbi.global. https://synthesismanual.jbi.global...
Massage
Gallo et al., 2013²⁶26 Gallo RBS, Santana LS, Ferreira CHJ, Marcolin AC, Polineto OB, Duarte G, Quintana SM. Massage reduced severity of pain during labour: a randomised trial. J Physiother 2013; 59(2):109-116.	30-min massage	23	23	Increase	Labor: 408	Labor: 342	Mean difference 1.1 hour; 95%CI: 0.2; 2.0	Low risk of bias¹²12 Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Systematic reviews of effectiveness. In: Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, editors. JBI Manual for Evidence Synthesis [Internet]. 2020 [cited 2023 jul 8]. Available from; https://synthesismanual.jbi.global. https://synthesismanual.jbi.global...
Positions adopted by mother
Desseauve et al., 2016²⁹29 Desseauve D, Gachon B, Bertherat P, Fradet L, Lacouture P, Pierre F. Dans quelle position les femmes accouchent-elles en 2015? Résultats d'une étude prospective régionale multicentrique. Gynécologie Obstétrique Fertil 2016; 44(10):548-556.	Dorsal decubitus during labor	431	120	Reduction	Labor classified as ≥120 or <120 minutes	OR=2.2 95%CI: 1.2; 4.2		Good quality¹⁵15 Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, Shekelle P, Stewart LA. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Rev 2015; 4:1.
Dorsal decubitus during expulsion	303	144	Increase	Labor classified as ≥120 or <120 minutes		OR=0.1 95%CI: 0.0; 0.4
Bomfim-Hyppólito,1998¹⁶16 Bomfim-Hyppólito S. Influence of the position of the mother at delivery over some maternal and neonatal outcomes. Int J Gynecol Obstetr 1998; 21(63):S67-S73.	Semi-sitting position (60º) in expulsion stage	127	121	No effect	Expulsion stage: 21.7	Expulsion stage: 25.1	p=0.06	High risk of bias¹²12 Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Systematic reviews of effectiveness. In: Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, editors. JBI Manual for Evidence Synthesis [Internet]. 2020 [cited 2023 jul 8]. Available from; https://synthesismanual.jbi.global. https://synthesismanual.jbi.global...
Maternal mobility
Desseauve et al., 2016²⁹29 Desseauve D, Gachon B, Bertherat P, Fradet L, Lacouture P, Pierre F. Dans quelle position les femmes accouchent-elles en 2015? Résultats d'une étude prospective régionale multicentrique. Gynécologie Obstétrique Fertil 2016; 44(10):548-556.	Switching position during labor	411	140	Increase	Labor classified as ≥120 or <120 minutes	OR=0.2 95%CI: 0.1; 0.3		Good quality¹⁵15 Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, Shekelle P, Stewart LA. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Rev 2015; 4:1.
Acupuncture/Acupressure/Auriculotherapy
Gaudernack et al., 2006²¹21 Gaudernack LC, Forbord S, Hole E. Acupuncture administered after spontaneous rupture of membranes at term significantly reduces the length of birth and use of oxytocin: a randomized controlled trial. Acta Obstet Gynecol Scand 2006; 85(11):1348-1353.	Acupuncture	43	48	Reduction	Active stage: 264	Active stage: 366	Mean Difference 1.7 hour; 95%CI: 0.2; 3.1	Low risk of bias¹²12 Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Systematic reviews of effectiveness. In: Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, editors. JBI Manual for Evidence Synthesis [Internet]. 2020 [cited 2023 jul 8]. Available from; https://synthesismanual.jbi.global. https://synthesismanual.jbi.global...
Mafetoni and Shimo, 2015²⁸28 Mafetoni RR, Shimo AKK. Efeitos da acupressão na evolução do parto e taxa de cesárea: ensaio clínico randomizado. Rev Saude Publica 2015; 49:9.	Acupressure at point BP6	38	30	Reduction	628.10	913.10	p=0.004	Low risk of bias¹²12 Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Systematic reviews of effectiveness. In: Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, editors. JBI Manual for Evidence Synthesis [Internet]. 2020 [cited 2023 jul 8]. Available from; https://synthesismanual.jbi.global. https://synthesismanual.jbi.global...
Mafetoni et al., 2018³⁶36 Mafetoni RR, Jacob LMS, Jorge HMF, Shimo AKK. Efeitos da auriculoterapia no tempo de trabalho de parto e taxa de cesárea: ensaio clínico randomizado. REME 2018; 22:e1139.	Auriculotherapy	25	27	No effect	607.8	694.7	p=0.08	Low risk of bias¹²12 Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Systematic reviews of effectiveness. In: Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, editors. JBI Manual for Evidence Synthesis [Internet]. 2020 [cited 2023 jul 8]. Available from; https://synthesismanual.jbi.global. https://synthesismanual.jbi.global...
Water birth
Schröcksnadel et al., 2003¹⁸18 Schröcksnadel H, Kunczicky V, Meier J, Brezinka C, Oberaigner W. Water Birth: experience at a university clinic and a district hospital in Austria. Gynakol Geburtshilfliche Rundsch 2003; 43(1):7-11.	Water birth in District Hospital	47	265	Reduction	Expulsion stage: 15	Expulsion stage: 20	p=0.02	Good quality14
	Water birth at University Hospital	218	265	No effect	Expulsion stage: 23	Expulsion stage: 20	Non-significant	Good quality14
Zanetti-Daellenbach et al., 2007²²22 Zanetti-Daellenbach RA, Tschudin S, Zhong XY, Holzgreve W, Lapaire O, Hösli I. Maternal and neonatal infections and obstetrical outcome in water birth. Eur J Obstet Gynecol Reprod Biol 2007; 134(1):37-43.	Water birth after immersion bath	89	146	No effect Reduction	Active stage: 330.5 Expulsion stage: 35.3	Active stage: 352.8 Expulsion stage: 49.1	Non-significant p<0.001	Good quality¹⁴14 Wells GA, Shea B, O'Connell D, Peterson J, Welch V, Losos M, Tugwell P. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses [Internet]. The Ottawa Hospital, Our Research; 2021 [cited 2023 jul 8]. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp.
Cortes et al., 2011²⁵25 Cortes E, Basra R, Kelleher CJ. Waterbirth and pelvic floor injury: a retrospective study and postal survey using ICIQ modular long form questionnaires. Eur J Obstet Gynecol Reprod Biol 2011; 155(1):27-30.	Water birth	78	48	Reduction	Expulsion stage: 43	Expulsion stage: 57	p=0.01	Good quality¹⁴14 Wells GA, Shea B, O'Connell D, Peterson J, Welch V, Losos M, Tugwell P. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses [Internet]. The Ottawa Hospital, Our Research; 2021 [cited 2023 jul 8]. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp.
Ulfsdottir et al., 2018³⁴34 Ulfsdottir H, Saltvedt S, Georgsson S. Waterbirth in Sweden: a comparative study. Acta Obstet Gynecol Scand 2018; 97(3):341-348.	Water birth	306	306	Reduction	Expulsion stage: 21.6	Expulsion stage: 26.8	p=0.01	Good quality¹⁴14 Wells GA, Shea B, O'Connell D, Peterson J, Welch V, Losos M, Tugwell P. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses [Internet]. The Ottawa Hospital, Our Research; 2021 [cited 2023 jul 8]. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp.
Neiman et al., 2020³⁸38 Neiman E, Austin E, Tan A, Anderson CM, Chipps E. Outcomes of waterbirth in a US Hospital-Based Midwifery practice: a retrospective cohort study of water immersion during labor and birth. J Midwifery Womens Health 2020; 65(2):216-223.	Water birth	58	111	Nulliparous Reduction Multiparous No effect	Nulliparous Expulsion stage: 23.2 Multiparous Expulsion stage: 9.5	Nulliparous Expulsion stage: 79.7 Multiparous Expulsion stage: 16.8	Nulliparous p=0.03 Multiparous p=0.08	Good quality¹⁴14 Wells GA, Shea B, O'Connell D, Peterson J, Welch V, Losos M, Tugwell P. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses [Internet]. The Ottawa Hospital, Our Research; 2021 [cited 2023 jul 8]. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp.
Pushing techniques in expulsion stage
Koyucu and Demirci, 2017³¹31 Koyucu RG, Demirci N. Effects of pushing techniques during the second stage of labor: A randomized controlled trial. Taiwan J Obstet Gynecol 2017; 56(5):606-612.	Spontaneous pushing	40	40	Increase	Expulsion stage: 63.2	Expulsion stage: 46.6	p<0.001	Low risk of bias¹²12 Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Systematic reviews of effectiveness. In: Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, editors. JBI Manual for Evidence Synthesis [Internet]. 2020 [cited 2023 jul 8]. Available from; https://synthesismanual.jbi.global. https://synthesismanual.jbi.global...
Vaziri et al., 2016³⁰30 Vaziri F, Arzhe A, Asadi N, Pourahmad S, Moshfeghy Z. Spontaneous pushing in lateral position versus valsalva maneuver during second stage of labor on maternal and fetal outcomes: a randomized clinical trial. Iran Red Crescent Med J 2016; 18(10):e29279.	Spontaneous pushing in lateral position	35	34	Increase	Expulsion stage: 76.32	Expulsion stage: 64.56	p<0.001	Some concerns¹²12 Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Systematic reviews of effectiveness. In: Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, editors. JBI Manual for Evidence Synthesis [Internet]. 2020 [cited 2023 jul 8]. Available from; https://synthesismanual.jbi.global. https://synthesismanual.jbi.global...
Techniques used in association
Almeida et al., 2005¹⁹19 Almeida NAM, Sousa JT, Bachion MM, Silveira NA. Utilização de técnicas de respiração e relaxamento para alívio de dor e ansiedade no processo de parturição. Rev Lat Am Enferm 2005; 13(1):52-58.	Breathing plus relaxation techniques	19	17	Increase No effect No effect	Latent stage: 145.26 Active stage: 173.68 Transition stage: 126.31	Latent stage: 84.70 Active stage: 151.76 Transition stage: 103.23	p=0.01 p=0.54 p=0.16	Some concerns¹²12 Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Systematic reviews of effectiveness. In: Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, editors. JBI Manual for Evidence Synthesis [Internet]. 2020 [cited 2023 jul 8]. Available from; https://synthesismanual.jbi.global. https://synthesismanual.jbi.global...
Cavalcanti et al., 2019³⁷37 Cavalcanti ACV, Henrique AJ, Brasil CM, Gabrielloni MC, Barbieri M. Terapias complementares no trabalho de parto: ensaio clínico randomizado. Rev Gaucha Enferm 2019; 40:e20190026.	Hot / warm shower plus birth ball exercises	39	44	No effect	From combined intervention to birth: 216.85	Hot shower to birth: 255.05	p=0.10	Low risk of bias¹²12 Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Systematic reviews of effectiveness. In: Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, editors. JBI Manual for Evidence Synthesis [Internet]. 2020 [cited 2023 jul 8]. Available from; https://synthesismanual.jbi.global. https://synthesismanual.jbi.global...
	Hot / warm shower plus birth ball exercises	39	45	No effect	From combined intervention to birth: 216.85	From birth ball exercises to birth: 288.41	p=0.10
Gallo et al., 2018⁸8 Gallo RBS, Santana LS, Marcolin AC, Duarte G, Quintana SM. Sequential application of non-pharmacological interventions reduces the severity of labour pain, delays use of pharmacological analgesia, and improves some obstetric outcomes: a randomised trial. J Physiother 2018; 64(1):33-40.	Ball exercises, lumbosacral massage plus warm/hot shower	40	40	No effect Reduction	Active stage: 373 Expulsion stage: 19	Active stage: 445 Expulsion stage: 37	95%CI: 148; 5 95%CI: 30; -5	Low risk of bias¹²12 Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Systematic reviews of effectiveness. In: Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, editors. JBI Manual for Evidence Synthesis [Internet]. 2020 [cited 2023 jul 8]. Available from; https://synthesismanual.jbi.global. https://synthesismanual.jbi.global...
Makvandi et al., 2018³³33 Makvandi S, Mirzaiinajmabadi K, Mirteimoori M, Esmaily H. Effect of normal physiologic childbirth program in mother-friendly hospitals on duration of labor. Electron J Gen Med 2018; 15(3):em21.	Immersion bath, birth ball exercise, aromatherapy with lavender and vertical positions during second stage of labor	77	77	Reduction No effect	Active stage: 210.02 Expulsion stage: 36.61	Active stage: 269.54 Expulsion stage: 43.08	p<0.001 p=0.08	Low risk of bias¹³13 Palmeri V, Colamesta V, La Torre G. Evaluation of methodological quality of studies. Senses Sci 2016; 3(3):235-224.
Bio et al., 2006⁷7 Bio E, Bittar RE, Zugaib M. Influência da mobilidade materna na duração da fase ativa do trabalho de parto. Rev Bras Ginecol Obstetr 2006; 28(11):671-679.	Mobility and alternating vertical postures	50	50	Reduction	Active stage: 316	Active stage: 508	p<0.001	Some concerns¹²12 Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Systematic reviews of effectiveness. In: Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, editors. JBI Manual for Evidence Synthesis [Internet]. 2020 [cited 2023 jul 8]. Available from; https://synthesismanual.jbi.global. https://synthesismanual.jbi.global...

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