BACKGROUND AND PURPOSE:

• Maternal posture during labor has been suggested to help with fetal malposition (occipito-posterior and persistent occipito-transverse), but evidence is conflicting
• Barrowclough et al. (Cochrane Database of Systematic Reviews, 2022) assessed the effect of specified maternal postures for women with fetal malposition in labor on maternal and infant morbidity

METHODS:

• Systematic review and meta-analysis
• Study Inclusion criteria
  • Randomized or cluster-randomized controlled trials
  • Laboring women with fetal malposition confirmed by ultrasound or clinical exam that compared maternal postures
• Study design
  • Outcomes were assessed with
    • Mean difference (MD) for continuous variables
    • Risk ratios (RRs) for dichotomous variables
  • Certainty of evidence was assessed using GRADE criteria
• Primary outcomes
  • Maternal: Operative birth
  • Neonatal: Serious morbidity

RESULTS:

• 8 studies | 1766 women
  • All studies were at high risk of bias due to lack of blinding

Hands and Knees

• Hands and knees posture may have little to no effect on
  • Operative birth
    • Average RR 1.14 (95% CI, 0.87 to 1.50)
    • 3 trials | 721 women; low-certainty evidence
  • Cesarean section
    • RR 1.34 (95% CI, 0.96 to 1.87)
    • 3 trials | 721 women; low-certainty evidence
• Evidence related to the benefit of hands and knees posture is very uncertain for the following
  • Epidural use
    • Average RR 0.74 (95% CI, 0.41 to 1.31)
    • 2 trials | 282 women; very low-certainty evidence
  • Instrumental vaginal birth
    • Average RR 1.04 (95% CI, 0.57 to 1.90)
    • 3 trials | 721 women; very low-certainty evidence
  • Severe perineal tears
    • Average RR 0.88 (95% CI, 0.03 to 22.30)
    • 2 trials | 586 women; very low-certainty evidence
  • Maternal satisfaction
    • Average RR 1.02 (95% CI, 0.68 to 1.54)
    • 3 trials | 350 women; very low-certainty evidence
  • Apgar scores less than seven at five minutes
    • RR 0.71 (95% CI, 0.21 to 2.34)
    • 2 trials | 586 babies; very low-certainty evidence

Lateral Postures

• The use of lateral postures may have little to no effect on reducing
  • Operative birth
    • Average RR 0.72 (95% CI, 0.43 to 1.19)
    • 4 trials | 871 women; low-certainty evidence
  • Cesarean section
    • Average RR 0.78 (95% CI, 0.44 to 1.39)
    • 4 trials | 871 women; low-certainty evidence
  • Instrumental vaginal birth
    • Average RR 0.73 (95% CI, 0.39 to 1.36)
    • 4 trials | 871 women; low-certainty evidence
  • Maternal satisfaction
    • RR 0.96 (95% CI, 0.84 to 1.09)
    • 2 trials | 451 women; low-certainty evidence
• The evidence is very uncertain about the effect of lateral postures on
  • Severe perineal tears
    • RR 0.66 (95% CI, 0.17 to 2.48)
    • 3 trials | 609 women; very low-certainty evidence
  • Postpartum hemorrhage     
    • RR 0.90 (95% CI, 0.48 to 1.70)
    • 1 trial | 322 women; very low-certainty evidence
  • Serious neonatal morbidity
    • RR 1.41 (95% CI, 0.64 to 3.12)
    • 3 trials | 752 babies; very low-certainty evidence
  • Apgar scores less than seven at five minutes
    • RR 0.25 (95% CI, 0.03 to 2.24)
    • 1 trial | 322 babies; very low-certainty evidence
  • NICU admission
    • RR 1.41 (95% CI, 0.64 to 3.12)
    • 2 trials | 542 babies; very low-certainty evidence
  • Neonatal death (stillbirth or death of liveborn)
    • 1 trial | 210 women and their babies; no events

CONCLUSION:

• The use of hands and knees and lateral maternal positioning during labor in the presence of fetal malposition may have little to no effect on maternal or neonatal outcomes, although evidence is of low- or very low-certainty
• The authors state

If a woman finds the use of hands and knees or lateral postures in labour comfortable there is no reason why they should not choose to use them

Further research is needed on the use of hands and knees and lateral postures for women with a malposition in labour

Learn More – Primary Sources:

Maternal postures for fetal malposition in labour for improving the health of mothers and their infants

Related ObG Topics:

Operative Vaginal Birth: Indications and Clinical Considerations

External Cephalic Version: Clinical Recommendations and Factors for Success

PROPOP RCT Results: Does Trial of Prophylactic Manual Rotation Reduce Operative Deliveries?