Maternal position and other variables: effects on perineal outcomes in 557 births

The second stage of labor

The second stage of labor extends from complete cervical dilatation to delivery. During this stage, descent and rotation of the presenting part occur as the fetus passively negotiates its passage through the birth canal. Generally, descent begins during the deceleration phase of dilatation as the cervix is drawn upward around the fetal presenting part. The most common means of assessing the normality of the second stage of labor is to measure its duration, but progress can be more meaningfully gauged by measuring the change in fetal station as a function of time. Accurate clinical identification and evaluation of differences in patterns of fetal descent are necessary to assess second stage of labor progress and to make reasoned judgments about the need for intervention. Three distinct graphic abnormalities of the second stage of labor can be identified: protracted descent, arrest of descent, and failure of descent. All abnormalities have a strong association with cephalopelvic disproportion but may also occur in the presence of maternal obesity, uterine infection, excessive sedation, and fetal malpositions. Interpretation of the progress of fetal descent must be made in the context of other clinically discernable events and observations. These include fetal size, position, attitude, and degree of cranial molding and related evaluations of pelvic architecture and capacity to accommodate the fetus, uterine contractility, and fetal well-being. Oxytocin infusion can often resolve an arrest or failure of descent or a protracted descent caused by an inhibitory factor, such as a dense neuraxial block. It should be used only if thorough assessment of fetopelvic relationships reveals a low probability of cephalopelvic disproportion. The value of forced Valsalva pushing, fundal pressure, and routine episiotomy has been questioned. They should be used selectively and where indicated.

Analysis of Maternal Positions during the Dilation and Expulsive Phase and Their Relationship with Perineal Injuries in Eutocic Deliveries Attended by Midwives

This cross-sectional descriptive study aimed to analyze the relationship between maternal positions during the expulsion phase and perineal outcomes in 367 eutocic births attended by midwives or midwifery residents at a public hospital in northern Spain in 2018. A total of 94.3% of women opted for horizontal positions. Limited sacral retroversion was observed in 71.7%, potentially influencing perineal outcomes. A low incidence of tears indicated effective management during the expulsive phase, with an episiotomy rate of 15.3%, which was slightly above the 15% standard. Primiparity and maternal age were identified as risk factors associated with episiotomy. Additionally, sacral mobilization and vertical positions during delivery were significantly related to fewer perineal injuries, suggesting benefits for both mother and newborn. The correlation between maternal positions and the need for epidural analgesia highlighted the importance of considering these in pain management during childbirth. Despite limitations, the study provides valuable insight into obstetric practices and advocates for a woman-centered approach that respects autonomy during childbirth. Further research is needed to explore biomechanical parameters and enhance childbirth experiences.

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.

Patterns in Second Stage Labor Care Practices Associated With Genital Tract Injury and Postpartum Hemorrhage During Physiologic Birth: A Latent Mixture Model Analysis

INTRODUCTION

Genital tract injury during childbirth contributes to short and long-term problems, including postpartum hemorrhage, incontinence, and pelvic organ prolapse. The purpose of this study was to examine which sets of second stage management techniques employed by midwives attending births in the community setting are associated with genital tract injury and subsequent postpartum hemorrhage.

METHODS

Data from primiparous individuals within the Midwives Alliance of North America (MANA) Stats 2.0 (2004–2009) database were used for this analysis. Latent mixture modeling identified classes (groups) within the sample that are most similar based on 11 different characteristics of second stage management as noted by midwives in their birth notes, including hands-on management techniques during birth, maternal positioning at birth, and water birth.

RESULTS

Three classes of second stage management techniques best fit this complex dataset. The patterns of techniques used by midwives were only marginally associated with better or worse genital tract outcomes independent of other factors. Two covariables, however, advanced maternal age (OR1.60, 95% CI 1.09–2.34) and births with low fetal heart rate during second stage (OR2.82, 95% CI 1.93–4.10)—were associated with severe genital tract injury. Postpartum hemorrhage was more likely for the two classes where midwives used more hands-on management during second stage, even when considering presence of genital tract injury (OR1.33, 95% CI 1.09–1.63). This study highlights the complex second stage circumstances that interact with management techniques, which together shape or contribute to both genital tissue and hemorrhage outcomes.

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.

Upright positions in childbirth and the prevention of perineal lacerations: a systematic review and meta-analysis

OBJECTIVE

To investigate whether the adoption of upright positions by women during childbirth prevents perineal lacerations compared to the lithotomy position.

METHOD

A systematic review with meta-analysis. The searches were carried out in the databases: LILACS, Medline/PubMed, CINAHL, Cochrane Library, Web of Science, Science Direct and Scopus. Searches in the gray literature were conducted on Google Scholar and OpenGrey databases. Reference lists of included articles were also considered. The Cochrane collaboration tool and ACROBAT-NRSI were used to analyze the methodological quality of the articles.

RESULTS

There were 26 studies listed and 8 were selected for the meta-analysis. The level of scientific evidence was classified by the GRADE System and considered high. There was no statistically significant difference between upright positions in relation to horizontal positions. Despite this finding, the upright positions showed reduced rates of severe perineal lacerations.

CONCLUSION

Adopting upright positions in normal delivery can be encouraged by professionals as it can prevent severe perineal lacerations; however, it is not possible to accurately affirm their effectiveness to the detriment of horizontal positions for an intact perineum outcome.

A review and comparison of common maternal positions during the second-stage of labor

The second-stage of labor is the most stressful part of childbirth process and the proper maternal position during this period is paramount for women's safe vaginal birth. Midwives play a pivotal role in managing maternal positions during the second-stage of labor. However, there is limited evidence to support an ideal maternal position during the second-stage of labor. Further, the difference between different maternal positions might not be apparent. This paper aims to review and compare the benefits and risks of common maternal positions during the second-stage of labor, thereby to provide midwives evidence-based practical guidelines.

Intact Perineum: What are the Predictive Factors in Spontaneous Vaginal Birth?

Introduction

Perineal trauma at birth is distressing for women and can cause serious short and long term morbidity.

Aim

Investigate the prevalence and predictive factors of intact perineum after normal vaginal birth among Portuguese women who had spontaneous vaginal births.

Methods

A descriptive, cross-sectional, retrospective study was carried out among pregnant women who had spontaneous vaginal births, between January 1, 2017, and December 31, 2017, in a single birth centre in Portugal. Following ethical approval, the prevalence of intact perineum was calculated and multivariate analysis with logistic regression was carried out, to identify the predictive factors of having an intact perineum after spontaneous vaginal birth.

Results

A total of 1748 pregnant women had spontaneous vaginal births. Four hundred and forty-one women (25.2%) had intact perineum whereas in 1307 (74.8%) of women, the perineum was not intact. First-degree tears occurred in 23.2% (405/1748) of women, second-degree tears occurred in 4% (70/1748) of women while three women (0.2%) experienced a third-degree tear. The rate of episiotomies was 43.8% (766/1748). Episiotomy and first-degree tears occurred in 2.6% (45/1748), episiotomy and second-degree tears occurred in 0.7% (12/1748), while episiotomy and third-degree tears occurred in 0.3% (6/1748) of women. Having a previous caesarean section reduced the odds of intact perineum by 60%, while nulliparity reduced the odds by 70%. For every 250 grams increase in birth weight, the odds of sustaining an intact perineum were decreased by 13%. Alternative birth positions (excluding lithotomy) doubled the odds of maintaining an intact perineum.

Conclusion

The prevalence of intact perineum is 25,2%. Predictive factors for intact perineum include birth weight, parity, previous caesarean section and birthing position. Recognizing these factors could support and facilitate the management of spontaneous vaginal birth to promote an intact perineum. Further research is needed to gain better understanding of this phenomenon.

Associations between improved care during the second stage of labour and maternal and neonatal health outcomes in a rural hospital in Bangladesh

OBJECTIVE

To evaluate the efficacy of care in the second stage of labour with a package of interventions that included (1) maintaining the birthing position according to the woman's choice, (2) adopting a spontaneous pushing technique and (3) using a support person, to reduce maternal and neonatal complications.

DESIGN

Used the data collected from two cohorts- before and after an initiative to improve care during the second stage of labour.

SETTING

A rural hospital in Bangladesh where 90-100 deliveries are conducted monthly and cesarean section provision is not available.

PARTICIPANTS

One thousand and fifty-one singleton pregnancies who attended the hospital for giving birth in the first stage of labour before full dilatation of the cervix and with cephalic presentation.

MEASUREMENTS AND FINDINGS

Data were collected through a structured checklist and questionnaire completed by research assistants; and also retrieved from hospital case record files, and the ongoing demographic surveillance system database. Coverage of adopting the upright or lateral position in the post-intervention period increased to 76% from about 1% in the pre-intervention period, and the spontaneous pushing technique increased to 97% from 77% in the same period. The odds of combined maternal and neonatal complications decreased by 46% between pre- and post-intervention periods (odds ratio: 0.54, 95% confidence interval: 0.43-0.70). Frequency of episiotomy (from 43% to 29%, P < 0.001), cervical tear (3.8% to 1.5%, P = 0.02), and median blood loss (200 ml to 150 ml; P < 0.001) were reduced significantly in the same period. No significant associations were observed in perineal tear or birth asphyxia occurrences.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The study suggests that there is a beneficial effect of care during the second stage of labour with a package of interventions in reducing maternal and neonatal complications, particularly in reducing the frequency of episiotomy, cervical tear, and blood loss during delivery. The preferred choice of posture during giving birth, adopting a spontaneous pushing technique and continuous presence of support person during the second stage of labour may be encouraged for better health outcomes.

Influence of a pelvic floor training programme to prevent perineal trauma: A quasi-randomised controlled trial

BACKGROUND

perineal injury is common after birth and may be caused by tears or episiotomy or both. Perineal massage has been shown to prevent episiotomies in primiparous women. On the other hand, pelvic floor exercises might have an influence by shortening the first and second stages of labour in the primigravida.

AIM

the aim of this study was to investigate the effects of a pelvic floor training following a birth programme on perineal trauma.

DESIGN

a single-blind quasi-randomized controlled trial with two groups: standard care and intervention.

SETTING

a tertiary, metropolitan hospital in Seville, Spain.

PARTICIPANTS

women (n=466) who were 32 weeks pregnant, having a singleton pregnancy and anticipating a normal birth were randomised. Women in the experimental groups were asked to perform a pelvic floor training programme that included: daily perineal massage and pelvic floor exercises from 32 weeks of pregnancy until birth. They were allocated to an intervention group by clusters (antenatal education groups) randomized 1:1. The control group had standard care that did not involve a perineal/pelvic floor intervention. These women were collected in a labour ward at admission 1:3 by midwives.

RESULTS

outcomes were analysed by intention-to-treat. Women assigned to the perineal/pelvic floor intervention showed a 31.63% reduction in episiotomy (50.56% versus 82.19%, p<0.001) and a higher likelihood of having an intact perineum (17.61% versus 6.85%, p<0.003). There were also fewer third (5.18% versus 13.12%, p<0.001) and fourth degree-tears (0.52% versus 2.5%, p<0.001). Women allocated to the intervention group also had less postpartum perineal pain (24.57% versus 36.30%, p<0.001) and required less analgesia in the postnatal period (21.14% versus 30.82%, p<0.001).

CONCLUSIONS

a training programme composed of pelvic floor exercises and perineal massage may prevent episiotomies and tears in primiparous women. This programme can be recommended to primiparous women in order to prevent perineal trauma.

KEY CONCLUSION

the pelvic floor programme was associated with significantly lower rates of episiotomies and severe perineal trauma; and higher intact perineum when compared with women who received standard care only.

IMPLICATIONS FOR PRACTICE

the programme is an effective intervention that we recommend to all women at 32nd week of pregnancy to prevent perineal trauma.

Non-surgical intrapartum practices for the prevention of severe perineal trauma: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to determine the effectiveness of non-surgical intrapartum practices in reducing the incidence of severe perineal trauma (third and fourth degree tears) during childbirth.

Mothers and midwives perceptions of birthing position and perineal trauma: An exploratory study

BACKGROUND

Studies have associated lithotomy position during childbirth with negative consequences and increased risk of perineal injuries.

AIMS

To identify prevalence rates of different birthing position and episiotomy and to explore the differences in perspectives of mothers and midwives about birthing positions and perineal trauma.

METHODS

A survey involving 110 mothers and 110 midwives at two hospitals. Participants were mothers who had a vaginal birth/perineal injury and midwives who attended births that resulted in perineal injuries. Perceptions of mothers and midwives were analysed. Pearson's chi-square test was used to measure association between birthing positions and perineal trauma.

FINDINGS

Mothers, n=94 (85%) and midwives, n=108 (98%) reported high rates of lithotomy position for birth. N=63 (57%) of mothers perceived lithotomy position as not being helpful for birth. In contrast, a similar number of midwives perceived lithotomy position as helpful, n=65 (59%). However, a high majority of mothers, n=106 (96%) and midwives, n=97 (88%) reported they would be willing to use alternative positions. Majority of mothers had an episiotomy, n=80 (73%) and n=76 (69%) reported they did not give their consent. N=59 (53%) reported they were not given local anaesthesia for an episiotomy. n=30 (27%) of midwives confirmed they performed an episiotomy without local anaesthesia.

CONCLUSION

Care is not based on current evidence and embedded practices, i.e. birthing in lithotomy position and routine episiotomies are commonly used. However, this survey did find a willingness to change, adapt practice and consider different birthing positions and this may lead to fewer episiotomies being performed.

Comparison of the Effect of Maternal Rest in Alternative Lateral Decubitus Positions on the Amniotic Fluid Index: A Randomized Controlled Trial

OBJECTIVES

To analyze the effect of maternal rest in the left and right lateral decubitus positions and resting alone on the amniotic fluid index (AFI).

METHOD

Sixty-nine women with singleton pregnancies and an AFI of 6 to 24 cm at 36 to 40 weeks' gestation were included in this randomized controlled trial. The women were randomized into 2 intervention groups. After initial AFI measurements, group 1 (n = 35) rested in the left lateral position for 15 minutes and then rested in the right lateral position for another 15 minutes. Group 2 (n = 34) rested in the right lateral position for 15 minutes and then rested in the left lateral position for another 15 minutes. To compare differences between groups, AFIs were measured at the end of each 15-minute period while the participants were kept on their backs in a semirecumbent position.

RESULTS

The demographic data, gestational ages, and initial AFI values did not differ between groups (P > .05). In group 1, the initial mean AFI ± SD of 12.25 ± 3.81 increased significantly during the first 15 minutes to 15.17 ± 4.27 and decreased significantly during the second 15 minutes to 13.30 ± 4.29 (P< .001); however, the 30-minute AFI was still significantly higher than the initial value (P = .008). In group 2, the initial AFI change during the first 15 minutes, from 12.83 ± 3.99 to 12.72 ± 3.87, was not significant (P> .05); however, it increased significantly to 15.63 ± 4.14 during the second 15 minutes (P< .001). The 30-minute AFI was still significantly higher than the initial value (P< .001).

CONCLUSIONS

Maternal rest in the right lateral decubitus position does not seem to either increase or decrease the AFI, and resting alone does not increase the AFI in the short term.

Women's choice of positions during labour: return to the past or a modern way to give birth? A cohort study in Italy

Background. Childbirth medicalization has reduced the parturient's opportunity to labour and deliver in a spontaneous position, constricting her to assume the recumbent one. The aim of the study was to compare recumbent and alternative positions in terms of labour process, type of delivery, neonatal wellbeing, and intrapartum fetal head rotation. Methods. We conducted an observational cohort study on women at pregnancy term. Primiparous women with physiological pregnancies and single cephalic fetuses were eligible for the study. We considered data about maternal-general characteristics, labour process, type of delivery, and neonatal wellbeing at birth. Patients were divided into two groups: Group-A if they spent more than 50% of labour in a recumbent position and Group-B when in alternative ones. Results. 225 women were recruited (69 in Group-A and 156 in Group-B). We found significant differences between the groups in terms of labour length, Numeric Rating Scale score and analgesia request rate, type of delivery, need of episiotomy, and fetal occiput rotation. No differences were found in terms of neonatal outcomes. Conclusion. Alternative maternal positioning may positively influence labour process reducing maternal pain, operative vaginal delivery, caesarean section, and episiotomy rate. Women should be encouraged to move and deliver in the most comfortable position.

[What is new about obstetrical interventions during labor and normal delivery?]

This systematic review of the literature reports studies published over the last five years (2008-2013) about interventions during labor and normal delivery. The points made concerning active management of labor, interventions aimed at improving maternal comfort, management of occiput posterior fetal presentations, management of second stage of labor and prevention techniques for perineal lesions. Although obstetrics remains an "art" to which training is mainly based on experience and clinical expertise, this "art" at present cannot live without the evidence-based medicine. Numerous randomized trials published and in process, demonstrate awareness of this reality in our specialty.

Incidence of and risk factors for perineal trauma: a prospective observational study

BACKGROUND

Our aim was to describe the range of perineal trauma in women with a singleton vaginal birth and estimate the effect of maternal and obstetric characteristics on the incidence of perineal tears.

METHODS

We conducted a prospective observational study on all women with a planned singleton vaginal delivery between May and September 2006 in one obstetric unit, three freestanding midwifery-led units and home settings in South East England. Data on maternal and obstetric characteristics were collected prospectively and analysed using univariable and multivariable logistic regression. The outcome measures were incidence of perineal trauma, type of perineal trauma and whether it was sutured or not.

RESULTS

The proportion of women with an intact perineum at delivery was 9.6% (125/1,302) in nulliparae, and 31.2% (453/1,452) in multiparae, with a higher incidence in the community (freestanding midwifery-led units and home settings). Multivariable analysis showed multiparity (OR 0.52; 95% CI: 0.30-0.90) was associated with reduced odds of obstetric anal sphincter injuries (OASIS), whilst forceps (OR 4.43; 95% CI: 2.02-9.71), longer duration of second stage of labour (OR 1.49; 95% CI: 1.13-1.98), and heavier birthweight (OR 1.001; 95% CI: 1.001-1.001), were associated with increased odds. Adjusted ORs for spontaneous perineal truama were: multiparity (OR 0.42; 95% CI: 0.32-0.56); hospital delivery (OR 1.48; 95% CI: 1.01-2.17); forceps delivery (OR 2.61; 95% CI: 1.22-5.56); longer duration of second stage labour (OR 1.45; 95% CI: 1.28-1.63); and heavier birthweight (OR 1.001; 95% CI: 1.000-1.001).

CONCLUSIONS

This large prospective study found no evidence for an association between many factors related to midwifery practice such as use of a birthing pool, digital perineal stretching in the second stage, hands off delivery technique, or maternal birth position with incidence of OASIS or spontaneous perineal trauma. We also found a low overall incidence of OASIS, and fewer second degree tears were sutured in the community than in the hospital settings. This study confirms previous findings of overall high incidence of perineal trauma following vaginal delivery, and a strong association between forceps delivery and perineal trauma.