Article type
Abstract
Background: Occiput-posterior (OP) and persistent occiput transverse (OT) malposition affects at least 25% of labours and is associated with maternal and neonatal morbidity including operative birth and admission to neonatal intensive care. The evidence for the use of maternal posture to improve these outcomes is unclear.
Objectives: This Cochrane Systematic Review aimed to assess the efficacy of specified maternal postures in labour for fetal malposition.
Methods: The Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov, and International Clinical Trials Registry Platform were searched. Randomised controlled trials (RCTs) or cluster RCTs comparing maternal posture in labour with other posture, for fetal malposition confirmed by sonographic or clinical assessment, were included. Quasi-RCTs and cross-over trials were ineligible. Primary outcomes were operative birth and serious neonatal morbidity. Two authors assessed trials for inclusion, risk of bias, and performed data extraction. Summaries used mean difference and risk ratios with 95% confidence intervals. Certainty of evidence was assessed using the GRADE approach.
Results: Eight trials (1766 participants) were included. All trials were judged high risk for performance bias due to lack of blinding, owing to the nature of labour care. In addition, heterogeneity and imprecision, resulted in low/very low certainty that hands and knees or lateral posture had no effect on operative birth, caesarean, instrumental vaginal birth, maternal satisfaction, epidural-use, severe perineal tears, postpartum haemorrhage, serious neonatal morbidity, low Apgar score, admission to neonatal intensive care or infant death. However, a direction of effect favouring lateral posture was observed for anterior fetal rotation after the intervention (Risk Ratio 0.72; Confidence Interval 0.46, 1.08), though relatively short duration interventions may have limited the sustainability of this effect by time of birth. No data were available on encephalopathy, respiratory support, and jaundice requiring phototherapy.
Conclusion: Hands and knees or lateral posture for OP malposition was not supported, however, there is no reason to not use these postures if women wish to or find them comfortable. Further research is needed to increase pooled data for all postures assessed, including semi-prone and same-side-as-fetus lateral postures, with or without hip hyperflexion, and interventions applied later in labour or of longer duration.
Objectives: This Cochrane Systematic Review aimed to assess the efficacy of specified maternal postures in labour for fetal malposition.
Methods: The Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov, and International Clinical Trials Registry Platform were searched. Randomised controlled trials (RCTs) or cluster RCTs comparing maternal posture in labour with other posture, for fetal malposition confirmed by sonographic or clinical assessment, were included. Quasi-RCTs and cross-over trials were ineligible. Primary outcomes were operative birth and serious neonatal morbidity. Two authors assessed trials for inclusion, risk of bias, and performed data extraction. Summaries used mean difference and risk ratios with 95% confidence intervals. Certainty of evidence was assessed using the GRADE approach.
Results: Eight trials (1766 participants) were included. All trials were judged high risk for performance bias due to lack of blinding, owing to the nature of labour care. In addition, heterogeneity and imprecision, resulted in low/very low certainty that hands and knees or lateral posture had no effect on operative birth, caesarean, instrumental vaginal birth, maternal satisfaction, epidural-use, severe perineal tears, postpartum haemorrhage, serious neonatal morbidity, low Apgar score, admission to neonatal intensive care or infant death. However, a direction of effect favouring lateral posture was observed for anterior fetal rotation after the intervention (Risk Ratio 0.72; Confidence Interval 0.46, 1.08), though relatively short duration interventions may have limited the sustainability of this effect by time of birth. No data were available on encephalopathy, respiratory support, and jaundice requiring phototherapy.
Conclusion: Hands and knees or lateral posture for OP malposition was not supported, however, there is no reason to not use these postures if women wish to or find them comfortable. Further research is needed to increase pooled data for all postures assessed, including semi-prone and same-side-as-fetus lateral postures, with or without hip hyperflexion, and interventions applied later in labour or of longer duration.