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      Maternal positioning to correct occipito-posterior fetal position in labour: a randomised controlled trial

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          Abstract

          Background

          The occipito-posterior (OP) fetal head position during the first stage of labour occurs in 10-34% of cephalic presentations. Most will spontaneous rotate in anterior position before delivery, but 5-8% of all births will persist in OP position for the third stage of labour. Previous observations have shown that this can lead to an increase of complications, such as an abnormally long labour, maternal and fetal exhaustion, instrumental delivery, severe perineal tears, and emergency caesarean section. Usual care in the case of diagnosis of OP position is an expectant management. However, maternal postural techniques have been reported to promote the anterior position of the fetal head for delivery. A Cochrane review reported that these maternal positions are well accepted by women and reduce back pain. However, the low sample size of included studies did not allow concluding on their efficacy on delivery outcomes, particularly those related to persistent OP position. Our objective is to evaluate the efficacy of maternal position in the management of OP position during the first stage of labour.

          Methods/design

          A randomised clinical trial is ongoing in the maternity unit of the Geneva University Hospitals, Geneva, Switzerland. The unit is the largest in Switzerland with 4,000 births/year. The trial will involve 438 women with a fetus in OP position, confirmed by sonography, during the first stage of the labour. The main outcome measure is the position of the fetal head, diagnosed by ultrasound one hour after randomisation.

          Discussion

          It is important to evaluate the efficacy of maternal position to correct fetal OP position during the first stage of the labour. Although these positions seem to be well accepted by women and appear easy to implement in the delivery room, the sample size of the last randomised clinical trial published in 2005 to evaluate this intervention had insufficient power to demonstrate clear evidence of effectiveness. If the technique demonstrates efficacy, it would reduce the physical and psychological consequences of complications at birth related to persistent OP position.

          Trial registration

          ClinicalTrials.gov, http://www.clinicaltrials.gov: (no. NCT01291355).

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          Most cited references18

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          Changes in fetal position during labor and their association with epidural analgesia.

          Ellice Lieberman, Lobin Lee, Rebecca K Davidson … (2005)
          To evaluate whether epidural analgesia is associated with a higher rate of abnormal fetal head position at delivery. We conducted a prospective cohort study of 1,562 women to evaluate changes in fetal position during labor by using serial ultrasound examinations. Ultrasound examinations were performed at enrollment, epidural administration, 4 hours after the initial ultrasonography if epidural had not been administered, and late in labor (> 8 cm). Information about fetal head position at delivery was obtained from the provider. Regardless of fetal head position at enrollment (occiput transverse, occiput posterior, or occiput anterior), most fetuses were occiput anterior at delivery (enrollment position: occiput transverse 78%, occiput posterior 80%, occiput anterior 83%, P = .1). Final fetal position was established close to delivery. Of fetuses that were occiput posterior late in labor, only 20.7% were occiput posterior at delivery. Changes in fetal head position were common, and 36% of women had an occiput posterior fetus on at least one ultrasound examination. Women receiving epidural did not have more occiput posterior fetuses at the enrollment (23.4% epidural versus 26.0 no epidural, P = .9) or the epidural/4-hour ultrasound examination (24.9% epidural, 28.3% no epidural), but did have more occiput posterior fetuses at delivery (12.9% epidural versus 3.3% no epidural, P = .002); the association remained in a multivariate model (adjusted odds ratio 4.0, 95% confidence interval 1.4-11.1). Fetal position changes are common during labor, with the final fetal position established close to delivery. Our demonstration of a strong association of epidural with fetal occiput posterior position at delivery represents a mechanism that may contribute to the lower rate of spontaneous vaginal delivery consistently observed with epidural.
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            Comparison of transvaginal digital examination with intrapartum sonography to determine fetal head position before instrumental delivery.

            K Nicolaides, C Hargreaves, E Tsoi … (2003)
            To investigate the accuracy of intrapartum transvaginal digital examination in defining the position of the fetal head before instrumental delivery. In 64 singleton pregnancies undergoing instrumental delivery the fetal head position was determined by transvaginal digital examination by the attending obstetrician. Immediately after or before the clinical examination, the fetal head position was determined by transabdominal ultrasound by a trained sonographer who was not aware of the clinical findings. The digital examination was considered to be correct if the fetal head position was within +/- 45 degrees of the ultrasound finding. The accuracy of the digital examination was examined in relation to maternal and fetal characteristics. Digital examination failed to define the correct fetal head position in 17 (26.6%) cases. In 12 of 17 (70.6%) errors the difference was >/= 90 degrees and in five (29.4%) the difference was between 45 degrees and 90 degrees. The accuracy of vaginal digital examination was 83% for occiput-anterior and 54% for occiput-lateral + occiput-posterior positions. Logistic regression analysis demonstrated significant independent contributions in explaining the variance in the accuracy of vaginal examination for the station of the fetal head, the position of the fetal head and the experience of the examining obstetrician. Digital examination during instrumental delivery fails to identify the correct fetal head position in about one quarter of cases. Copyright 2003 ISUOG. Published by John Wiley & Sons, Ltd.
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              Intrapartum sonography to determine fetal head position.

              Anita R. Howard, K Nicolaides, E Tsoi … (2002)
              To investigate the accuracy of intrapartum transvaginal digital examination in defining the position of the fetal head. In 496 singleton pregnancies in labor at term, the fetal head position was determined by routine transvaginal digital examination by the attending midwife or obstetrician. Immediately before or after the clinical examination, the fetal head position was determined using transabdominal ultrasound by an appropriately trained sonographer who was not aware of the clinical findings. The digital examination was considered to be correct if the fetal head position was within 45 degrees of the ultrasound finding. The accuracy of the digital examination was examined in relation to maternal characteristics and the progress of labor. The position of the fetal head was determined by ultrasound examination in all 496 cases examined. Digital examination failed to define the fetal head position in 166 (33.5%) cases and, in 330 cases where the position was determined, the findings of the digital and sonographic examinations were in agreement in only 163 (49.4%) cases. The rate of correct identification of the fetal position by digital examination increased with cervical dilatation, from 20.5% at 3-4 cm to 44.2% at 8-10 cm, and was higher if the examination was carried out by an obstetrician than a midwife (50% versus 30%) and if there was absence rather than presence of caput (33% versus 25%). Routine digital examination during labor fails to identify the correct fetal position in the majority of cases.
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                Author and article information

                Contributors
                Marie-Julia Guittier
                Véronique Othenin-Girard
                Olivier Irion
                Michel Boulvain
                Journal
                Journal ID (nlm-ta): BMC Pregnancy Childbirth
                Journal ID (iso-abbrev): BMC Pregnancy Childbirth
                Title: BMC Pregnancy and Childbirth
                Publisher: BioMed Central
                ISSN (Electronic): 1471-2393
                Publication date Collection: 2014
                Publication date (Electronic): 24 February 2014
                Volume: 14
                Page: 83
                Affiliations
                [1 ]University of Applied Sciences Western Switzerland, 47 Avenue de Champel, Geneva 1206, Switzerland
                [2 ]Department of Gynaecology and Obstetrics, Geneva University Hospitals and Faculty of Medicine, 47 Avenue de Champel, Geneva 1206, Switzerland
                Article
                Publisher ID: 1471-2393-14-83
                DOI: 10.1186/1471-2393-14-83
                PMC ID: 3942064
                PubMed ID: 24564746
                SO-VID: 75f127c2-c8a2-48e0-b139-36b256eb8052
                Copyright © Copyright © 2014 Guittier et al.; licensee BioMed Central Ltd.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 1 February 2014
                Date accepted : 14 February 2014
                Categories
                Subject: Study Protocol

                ScienceOpen disciplines: Obstetrics & Gynecology
                Keywords: fetal head position,occipito-posterior,maternal position,randomised controlled trial,second stage of labour
                Data availability:
                ScienceOpen disciplines: Obstetrics & Gynecology
                Keywords: fetal head position, occipito-posterior, maternal position, randomised controlled trial, second stage of labour

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