Effects of flexible sacrum positions during the second stage of labour on maternal and neonatal outcomes: A systematic review and meta-analysis

Women's experience of adopting lateral positions during the second stage of labour compared with conventional lithotomy positions: A cross-sectional study

AIMS

Maternal positions during childbirth play an important role in safe vaginal births and might also influence women's childbirth experiences greatly. Lateral positions, as a potential position to reduce negative maternal and neonatal outcomes, have become popular in recent years, especially in China where the adoption of conventional lithotomy positions is still common. However, the childbirth experience of those who gave birth in lateral positions has been rarely studied. This study aimed to describe and compare women's childbirth experiences of adopting the newly introduced lateral positions and the conventional lithotomy positions during the second stage of labour.

STUDY DESIGN

A cross-sectional study was conducted in two tertiary hospitals in China involving a total of 658 primiparous and parous women who adopted lateral and lithotomy positions during the second stage of labour from July to November 2020. Sociodemographic characteristics, maternal and neonatal outcomes as well as childbirth experience assessed by the Childbirth Experience Questionnaire (CEQ) were collected. This study followed the STROBE guidelines.

RESULTS

Women who once adopted lateral positions during the second stage of labour had better positive childbirth experiences compared with those in the lithotomy positions group, as demonstrated by their overall higher CEQ scores. Women in the lateral position group also reported better participation and perceived safety, and a greater sense of control during childbirth. Lateral positions remained an influential factor in CEQ scores after controlling for potential confounders. In this study, adverse maternal and neonatal outcomes were rare. Women in lateral positions had comparatively better perineal outcomes.

CONCLUSION

This study described and compared women's childbirth experiences of adopting conventional lithotomy positions and lateral positions during the second stage of labour using a valid instrument. Women who adopted lateral positions during the second stage of labour reported better childbirth experiences than those giving birth in the conventional lithotomy positions. Thus, assisting women in giving birth in lateral positions might be a promising way to improve women's childbirth experience.

Midwives' practices on perineal protection and episiotomy decision-making: A qualitative and descriptive study

INTRODUCTION

Perineal trauma is associated with both short- and long-term morbidity which in turn relates to the degree of trauma. The objective of this study was to understand midwives' practices regarding perineal protection during the second phase of labor, emphasizing decision-making to perform an episiotomy.

METHODS

A descriptive and explanatory study was conducted with an intentional sample of twenty-two midwives working in the labor ward of a tertiary hospital in a metropolitan location and in the public service, in Portugal. A semi-open interview was applied to collect the data from 5 to 15 January 2019. The computer software package, NVivo version 10, was used to perform the thematic analysis.

RESULTS

Four main themes arose from the midwives' data: 1) Factors affecting the application of perineal protection techniques', 2) Birth position, 3) Techniques for perineal protection, and 4) Episiotomy. The reasons for performing an episiotomy were the presence of tense perineum, large weight baby, previous obstetric anal sphincter injury, and Kristeller maneuver.

CONCLUSIONS

Midwives' practices regarding perineal protection techniques and reasons for performing an episiotomy were not all in line with the evidence. Perineal massage was not mentioned as a perineal protection technique.

Effects of flexible sacrum position at birth on maternal and neonatal outcomes: A retrospective cohort study

OBJECTIVE

To examine the differences in both maternal and neonatal outcomes between flexible and non-flexible sacrum positions at birth.

METHODS

A descriptive, cross-sectional, retrospective study was carried out on a sample of low-risk pregnant women. Univariate and multivariate logistic regressions and multivariate linear regressions were conducted to estimate the association between our discrete or continuous variables of interest. Maternal outcomes were perineal tear, maternal blood loss, second stage length; neonatal outcomes were Apgar scores and neonatal asphyxia. Results were adjusted for maternal age, neonatal birth weight, and epidural analgesia.

RESULTS

We considered for final analysis 2198 women. In primiparous women, women giving birth in the all-fours position were significantly more likely to have an intact perineum (P = 0.011) and a shorter length of the second stage of labor (P = 0.022). Maternal age (P = 0.005) and neonatal weight (P = 0.013) significantly increased perineal tearing; maternal age (P = 0.004) and neonatal birth weight (P < 0.001) were significantly associated with a higher amount of blood loss. Maternal age (P = 0.002) and neonatal weight (P < 0.001) significantly increased the length of the second stage of labor. For multiparous women, the side-lying position was significantly correlated with an intact perineum (P = 0.031); maternal age and intact perineum were statistically inversely associated. Epidural analgesia significantly increased the length of the second stage of labor in both nulliparous (P < 0.001) and pluriparous women (P < 0.001). No significant differences were found in neonatal outcomes.

CONCLUSION

Women with a low-risk labor should be free to choose their birth position as flexible sacrum positions are shown to increase maternal well-being and do not affect neonatal health.

Vacuum-assisted birth in maternal lateral posture versus lithotomy. A simulation study

OBJECTIVE

Maternal lateral postures provide advantages during childbirth. This study aims to investigate the feasibility of assisting vacuum births in maternal lateral postures in a simulation model.

STUDY DESIGN

In a simulation model, four obstetricians and four medical students were randomly allocated to perform vacuum-assisted births first in maternal lateral posture or lithotomy. A modification of Aldo Vacca's 5-step technique was developed to assist vacuum-assisted births in lateral posture. The lateral distance, vertical distance, and distance from the cup center to the flexion point were measured for every placement of the cup.

RESULTS AND CONCLUSIONS

A total of 128 vacuum-assisted births were performed. The mean distance to the flexion point was 1.15 ± 0.71 cm for the lithotomy posture and 1.31 ± 0.82 cm for the lateral posture (P = 0.127). There were no statistically significant differences in vacuum extractor cup placement accuracy based on maternal posture. Performing vacuum-assisted births in maternal lateral posture is feasible in a simulation model. The technique is easy to learn, and the differences in cup placement between the lateral and lithotomy postures are small.

Australian women's experiences of wearing a non-invasive fetal electrocardiography (NIFECG) device during labour

BACKGROUND

Continuous electronic fetal monitoring devices can restrict women's freedom of movement and choice of positioning during labour and birth. Despite the use of continuous electronic fetal monitoring for the past 50 years, little attention has been paid to women's experiences of wearing different fetal monitoring devices in labour.

AIM

To explore women's views and experiences of wearing a beltless continuous electronic fetal monitoring device, the non-invasive fetal electrocardiogram during labour.

METHODS

A qualitative descriptive approach was taken. Recruitment was via a larger clinical feasibility study. Some women who consented to take part in the clinical feasibility study also consented to being interviewed during the postnatal period. Transcripts were thematically analysed.

FINDINGS

Women reported improved comfort when wearing the non-invasive fetal electrocardiogram device. They appreciated how it enabled freedom of movement and an ability to actively participate in labour. They compared their experience with previous use of cardiotocography which they felt compromised their bodily autonomy. All forms of continuous electronic fetal monitoring experienced by women resulted in the unwelcome experience of 'Poking and prodding' by the midwife.

DISCUSSION

Continuous electronic fetal monitoring can negatively impact women's labour and birth experience, particularly when the measurement of fetal wellbeing is prioritised.

CONCLUSION

The way in which continuous electronic fetal monitoring technology is designed and used is an important component of optimising physiological processes and positive experiences for women during labour and birth for women with complex pregnancies. Non-invasive fetal electrocardiograpy is a promising additional option for women.

Costs and intermediate outcomes for the implementation of evidence-based practices of midwifery under a MIDWIZE framework in an urban health facility in Nairobi, Kenya

BACKGROUND

Three evidence-based midwife-led care practices: dynamic birth positions (DBP), immediate skin-to-skin contact (SSC) with zero separation between mother and newborn, and delayed cord clamping (DCC), were implemented in four sub-Saharan African countries after an internet-based capacity building program for midwifery leadership in quality improvement (QI). Knowledge on costs of this QI initiative can inform resource mobilization for scale up and sustainability.

METHODS

We estimated the costs and intermediate outcomes from the implementation of the three evidence-based practices under the midwife-led care (MIDWIZE) framework in a single facility in Kenya through a pre- and post-test implementation design. Daily observations for the level of practice on DBP, SSC and DCC was done at baseline for 1 week and continued during the 11 weeks of the training intervention. Three cost scenarios from the health facility perspective included: scenario 1; staff participation time costs ($515 USD), scenario 2; staff participation time costs plus hired trainer time costs, training material and logistical costs ($1318 USD) and scenario 3; staff participation time costs plus total program costs for the head trainer as the QI leader from the capacity building midwifery program ($8548 USD).

RESULTS

At baseline, the level of DBP and SSC practices per the guidelines was at 0 % while that of DCC was at 80 %. After 11 weeks, we observed an adoption of DBP practice of 36 % (N = 111 births), SSC practice of 79 % (N = 241 births), and no change in DCC practice. Major cost driver(s) were midwives' participation time costs (56 %) for scenario 1 (collaborative), trainers' material and logistic costs (55 %) in scenario 2(collaborative) and capacity building program costs for the trainer (QI lead) (94 %) in scenario 3 (programmatic). Costs per intermediate outcome were $2.3 USD per birth and $0.5 USD per birth adopting DBP and SSC respectively in Scenario 1; $6.0 USD per birth adopting DBP and $1.4 USD per birth adopting SSC in Scenario 2; $38.5 USD per birth adopting DBP and $8.8 USD per birth adopting SSC in scenario 3. The average hourly wage of the facility midwife was $4.7 USD.

CONCLUSION

Improving adoption of DBP and SSC practices can be done at reasonable facility costs under a collaborative MIDWIZE QI approach. In a programmatic approach, higher facility costs would be needed. This can inform resource mobilization for future QI in similar resource-constrained settings.

Intrapartum ultrasound in maternal lateral versus semi-recumbent posture. A repeated measures study

OBJECTIVE

This study aimed to assess whether intrapartum ultrasound (ITU) measurements in maternal lateral posture are superimposable to ITU measurements in semi-recumbent position.

STUDY DESIGN

A single-center, repeated measures design was used. Women in the second stage of labor were randomized to ITU first in semi-recumbent followed by ITU in side-lying posture without and with contraction, or inversely. The angle of progression (AOP) and the head-perineum distance (HPD) between contractions (AOP1 and HPD1) and with contraction (AOP2 and HPD2) were measured in each maternal posture. The differences between AOP1 and AOP2 (dAOP), and between HPD1 and HPD2 (dHPD) were calculated.

RESULTS AND CONCLUSIONS

Forty-two women participated in the study. A generalized estimating equation model showed that AOP1 (-3.00°; 95 % CI -5.77 to -0.23; p = 0.03) and AOP2 (-4.14°; 95 % CI -7.20 to -1.08; p = 0.008) were lower in semi-recumbent compared to maternal lateral posture. HPD1 (+1.43 mm; 95 % CI 0.05-2.81; p = 0.042) and HPD2 (+1.53 mm; 95 % CI 0.17-2.89; p = 0.03) were higher in semi-recumbent position. Differences in the ITU measurements in maternal lateral posture compared to semi-recumbent position are small. Monitoring the second stage of labor with ITU in lateral maternal posture is possible.

Effect of Flexible Sacrum Position on Maternal and Neonatal Outcomes in Public Health Facilities, Amhara Regional State, Ethiopia: A Quasi-Experimental Study

Restricting women giving birth in health care facilities from choosing the most comfortable position during labor and birth is a global problem. This study was aimed to examine the effect of flexible sacrum birth positions on maternal and neonatal outcomes in public health facilities in Ethiopia's Amhara Region. A non-equivalent control group post-test-only design was employed at public health facilities from August to November 2019. A total of 1048 participants were enrolled and assigned to intervention or control groups based on their choice of birth position. Participants who preferred the flexible sacrum birth position received the intervention, while participants who preferred the supine birth position were placed in the control group. Data were collected using observational follow-up from admission to immediate postpartum period. Log binomial logistic regression considering as treated analysis was used. Of the total participants, 970 women gave birth vaginally, of whom 378 were from the intervention group, and 592 were from the control group. The intervention decreased the chance of perineal tear and poor Apgar score by 43 and 39%, respectively. The flexible sacrum position reduced the duration of the second stage of labor by a mean difference of 26 min. Maternal and newborn outcomes were better in the flexible sacrum position.

A biomechanical study of the birth position: a natural struggle between mother and fetus

Birth trauma affects millions of women and infants worldwide. Levator ani muscle avulsions can be responsible for long-term morbidity, associated with 13-36% of women who deliver vaginally. Pelvic floor injuries are enhanced by fetal malposition, namely persistent occipito-posterior (OP) position, estimated to affect 1.8-12.9% of pregnancies. Neonates delivered in persistent OP position are associated with an increased risk for adverse outcomes. The main goal of this work was to evaluate the impact of distinct fetal positions on both mother and fetus. Therefore, a finite element model of the fetal head and maternal structures was used to perform childbirth simulations with the fetus in the occipito-anterior (OA) and OP position of the vertex presentation, considering a flexible-sacrum maternal position. Results demonstrated that the pelvic floor muscles' stretch was similar in both cases. The maximum principal stresses were higher for the OP position, and the coccyx rotation reached maximums of 2.17[Formula: see text] and 0.98[Formula: see text] for the OP and OA positions, respectively. Concerning the fetal head, results showed noteworthy differences in the variation of diameters between the two positions. The molding index is higher for the OA position, with a maximum of 1.87. The main conclusions indicate that an OP position can be more harmful to the pelvic floor and pelvic bones from a biomechanical point of view. On the other side, an OP position can be favorable to the fetus since fewer deformations were verified. This study demonstrates the importance of biomechanical analyses to further understand the mechanics of labor.

Exploring midwives' experiences of implementing the Labour Hopscotch Framework: A midwifery innovation

INTRODUCTION

Midwives are ideally placed to promote physiological birth and improve women's birth experiences. Freedom of movement in labor is highly recommended as it reduces a need for obstetric interventions in labor and prevents and corrects labor complications, such as poor progress and malposition of the fetus. The Labour Hopscotch Framework (LHF) provides women and midwives with a visual depiction of the steps they can undertake to remain active and, in this way, support physiological birth processes. The objective of this study was to explore midwives' experiences of supporting women during labor with the Labour Hopscotch Framework and identify any improvements necessary to the Labour Hopscotch Framework.

METHODS

A two phased mixed-method sequential explanatory design study consisting of a survey (women, n=809 and partners, n=759) and focus group (n=8 midwives) was completed to evaluate the LHF following its implementation. This article presents the findings reporting midwives' perceptions of using the Labour Hopscotch Framework with women and their birthing partners. The setting was a large urban teaching maternity hospital in Dublin, Ireland, where eight midwives practiced in the following areas: labor suite, antenatal unit, and community midwifery.

RESULTS

The Labour Hopscotch Framework was described as beneficial in promoting physiological birth, using a creative, attractive visual depiction to guide women in, and before, labor. The Labour Hopscotch Framework was deemed helpful in increasing midwifery students and newly qualified midwives' confidence to provide women with tangible, supportive assistance during labor and increased partners' involvement in the labor process.

CONCLUSIONS

Labour Hopscotch Framework should be more widely promoted to all women attending the hospital for maternity care and a clear explanation of each step given and demonstrated to increase women's understanding of the steps within. Labour Hopscotch training should be included in midwifery education programs.

Comparison of perineal outcomes in Chinese women adopting lateral positions and lithotomy positions during the passive and active phases of the second stage of labour: An observational study

AIMS

To compare the effects of the adoption of lateral positions and lithotomy positions during the passive and active phases of the second stage of labour on perineal outcomes.

DESIGN

An observational study with prospectively collected data, conducted in three hospitals in China.

METHOD

Attending midwives recorded the perineal outcomes and characteristics of women giving birth between July-November 2020. Binary logistic regression was performed to explore the effects of lateral positions on perineal outcomes during different phases of the second stage of labour. The STROBE guidelines guided the reporting of this study.

RESULTS

Among primiparous women, when compared with those who adopted lateral positions during the passive phase of the second stage of labour and changed to lithotomy positions during the active phase, women who assumed lateral positions during both the passive and active phases had a higher rate of intact perineum/first-degree perineal tears and a reduced risk of episiotomy, and episiotomy/second-degree perineal tears. No significant difference was found in perineal outcomes between those who assumed lithotomy positions during the passive and active phases and those who adopted lateral positions during the passive phase and changed to lithotomy positions during the active phase. No significant difference was found in perineal outcomes among multiparous women, regardless of different positions adopted at the passive and/or the active phase.

CONCLUSION

Lateral positions during the active phase may have protective effects on the perineum in primiparous women. However, adopting lateral positions only during the passive phase did not promote better perineal outcomes, regardless of parity.

RELEVANCE TO CLINICAL PRACTICE

This study will provide a further reference for the use of lateral positions during different phases of the second stage of labour among primiparous and multiparous women in clinical practice, contributing to the perineal protection during childbirth.

Pelvic capacity in pregnant women, identified using magnetic resonance imaging

INTRODUCTION

Maternal pelvic capacity plays a major role during childbirth because the passage of the fetus through the bony birth canal enables vaginal birth. Maternal birthing position may influence pelvic capacity because upright positions optimize capacity, possibly due to free movement of the pelvic joints. Herein, pelvic capacity was assessed by comparing changes in pelvic dimensions across pregnancy and in three birthing positions.

MATERIAL AND METHODS

This diagnostic imaging study of 50 pregnant women was conducted at Aarhus University Hospital, Denmark. Pelvic measurements were obtained with 1.5 T magnetic resonance pelvimetry during gestational weeks 20 and 32, in three birthing positions: kneeling squat, semi-lithotomy and supine. Pelvic capacity was compared between gestational weeks and positions.

RESULTS

In all three positions there is an overall increase in pelvic capacity from gestational week 20-32 at both the pelvic inlet and outlet. Comparing pelvic capacity at gestational week 32 between the semi-lithotomy and supine positions revealed that the pelvic inlet was larger in the supine position, whereas the mean pelvic outlet was 0.2 cm (p < 0.001) larger in the semi-lithotomy position. Likewise, the pelvic inlet was larger in the supine than in the kneeling squat position. Shifting from supine to kneeling squat position increased the midplane and pelvic outlet dimensions by up to 1 cm (p < 0.001).

CONCLUSIONS

The finding herein of an increased pelvic capacity as the pregnancy progresses is novel. Further, the results indicate that the supine position is optimal for increasing pelvic inlet size, whereas the semi-lithotomy and kneeling squat positions are optimal for increasing mid- and outlet-pelvic capacities.

Maternal positions during labor: Midwives' knowledge and educational needs in northern Italy

INTRODUCTION

Maternal positions and mobility during childbirth can have different and specific effects on labor and affect some birth outcomes. The aim of the survey is to investigate the knowledge and skills regarding maternal positions in labor among midwives and to consider the need of training.

METHODS

A semi-structured questionnaire was distributed in August and September 2020 among midwives working in eight hospitals of Brescia, Northern Italy. The sample consisted of 115 midwives and data were analyzed using a quantitative, descriptive approach.

RESULTS

The majority of the sample identified the general and specific benefits of maternal positions. Factors limiting the proposal of maternal positions were the context, the relationships with healthcare providers, the woman features, the fetal heart rate registration, continuous cardiotocography, amniotomy, episiotomy, operative vaginal birth, and epidural analgesia. Vaginal examination, the detection of uterine contractions, intrapartum ultrasounds, and 'hands-on' perineum technique were considered irrelevant by the participating midwives. The promoting factors were the presence of the partner, the telemetry, and the partogram with a section dedicated to positions. Nearly the totality of the sample considered appropriate to deepen the topic with training.

CONCLUSIONS

Post-graduate courses are desirable to improve midwives' skills. An educational toolkit is proposed to make the promotion of maternal positions more effective and appropriate. In order to improve midwifery intrapartum care, further research addressed to midwives of other settings appears essential to compare different training contexts, to expand the proposed toolkit, and to invest on midwifery practice and education.

Effect of the birthing position on its evolution from a biomechanical point of view

BACKGROUND AND OBJECTIVE

During vaginal delivery, several positions can be adopted by the mother to be more comfortable and to help the labor process. The positions chosen are very influenced by factors such as monitoring and intervention during the second stage of labor. However, there is limited evidence to support the most ideal birthing position. This work aims at contributing to a better knowledge associated with the widening of the pubic symphysis and the biomechanics of flexible and non-flexible sacrum positions that can be adopted during the second stage of labor, as well as their resulting pathophysiological consequences.

METHODS

A validated computational model composed by the pelvic floor muscles attached to the bones, and a fetus head was used to simulate vaginal deliveries. This model was modified to mimic two birthing positions: one that allows the free movement of the coccyx as in flexible sacrum positions and other in which this movement is more restricted as in non-flexible sacrum positions. The widening of the pubic symphysis was also considered to facilitate the passage of the fetus head.

RESULTS

The results obtained showed that, in non-flexible sacrum positions, where the coccyx movement is restricted, occur a rotation of 3.6° of the coccyx and a widening of 6 mm of the pubic symphysis. In contrast, in flexible sacrum positions, where the coccyx is free to move, occur a rotation of 15.7° of the coccyx and a widening of the pubic symphysis of 3 mm, appearing to be more beneficial for the mother's pelvis, but slightly higher stresses were detected in the pelvic floor muscles.

CONCLUSIONS

Globally, the results obtained allow to conclude that different birthing positions lead to changes in the female pelvic space, so certain positions can be adopted by the mother during the second stage of labor to reduce the risk of obstructed labor and the development of several dysfunctions. More specifically, flexible sacrum positions, such as kneeling, standing, squatting and sitting positions, are more beneficial for the bone structure of her pelvis as they allow a higher coccyx movement and lower widening of the pubic symphysis.

Current Resources for Evidence-Based Practice, March 2021

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of men's experiences of pregnancy loss and commentaries on reviews focused on the effects of perineal massage on perineal trauma and air pollution and heat exposure on birth outcomes.