Maternal Posturing During Labor

apsaeaa

Research www.AJOG.org

OBSTETRICS

Is maternal posturing during labor efficient inpreventing persistent occiput posteriorposition? A randomized controlled trialRaoul Desbriere, MD; Julie Blanc, MD; Renaud Le Dû, MD; Jean-Paul Renner, MD;Xavier Carcopino, MD, PhD; Anderson Loundou, PhD; Claude d’Ercole, MD

OBJECTIVE: We sought to evaluate the efficacy of maternal posturingduring labor on the prevention of persistent occiput posterior (OP)position.

STUDY DESIGN: We conducted a randomized trial including 220 pa-tients in labor with a single fetus in documented OP position. Main out-come was the proportion of anterior rotation from OP position.

RESULTS: The rates of anterior rotation were, respectively, 78.2% and76.4% in the intervention group and the control group without signifi-cant difference (P � .748). Rates of instrumental and cesarean sectiondeliveries were not significantly different between intervention and con-trol groups (18.2% vs 19.1%, P � .89, and 19.1% vs 17.3%, P � .73,
respectively). In intervention and control groups, persistent OP position
randomized controlled trial. Am J Obstet Gynecol 2013;208:60.e1-8.

sttstp43d

0002-9378/$36.00 • © 2013 Mosby, Inc. All rights reserved. • http://dx.doi.org/10.10

60.e1 American Journal of Obstetrics & Gynecology JANUARY 2013

rates were significantly higher among women who had cesarean sec-tion (71.4% and 89.5%, respectively) and an instrumental delivery(25% and 33.3%, respectively) than among women who achievedspontaneous vaginal birth (5.8% and 2.8%, respectively). In multivari-able analysis, body mass index and parity were found to have significantand independent impact on the probability of fetal head rotation.

CONCLUSION: Our study failed to demonstrate any maternal or neona-tal benefit to a policy of maternal posturing for the management of OPposition during labor.

Key words: fetal malposition, persistent occiput posterior position,
posture
Cite this article as: Desbriere R, Blanc J, Le Dû R, et al. Is maternal posturing during labor efficient in preventing persistent occiput posterior position? A

uufhsiit

W ith an estimated prevalence rang-ing from 2-13% at delivery, per-

sistent occiput posterior (OP) position isthe most common malposition in la-bor1-7 and is associated with maternalnd neonatal morbidities. Thus it ex-oses not only to prolonged first andecond stages of labor, use of epiduralnalgesia, postpartum hemorrhage, cesar-an and operative vaginal delivery, third-nd fourth-degree perineal lacerations,nd chorioamnionitis1,4-7 but also to low

Apgar score, neonatal trauma, acidemic

From the Department of Obstetrics and GynecoDepartment of Obstetrics and Gynecology, Ass(APHM), Hôpital Nord (Drs Blanc, Le Dû, CarcopMarseille, Université de la Méditerranée (Drs Le DCenter, APHM, Université de la Méditerranée, N(Inserm) (Dr Le Dû); and the Department of Publ(DRC)/APHM, Faculty of Medicine (Dr Loundou)Gynecology, Assistance Publique des HôpitauxFrance.

Received June 5, 2012; revised Sept. 8, 2012; a

The authors report no conflict of interest.

Reprints: Raoul Desbriere, MD, Service de Gyné26 Boulevard de Louvain, 13008 Marseille, Fran

cord blood gas concentrations, admis-sion to neonatal intensive care unit, andnewborn encephalopathy.5-9 Severaltudies based on ultrasound examina-ion during labor have demonstratedhat the vast majority of OP deliveries re-ults from the failure of rotation fromhis position.10-13 Thus, the rate of OPosition has been estimated to be 30-0% at the early stage of active labor, 20-0% at 10-cm dilatation, and 5-10% atelivery.10-13 Various methods haveeen considered to rotate an OP fetus:

y, Hôpital St Joseph (Dr Desbriere); thence Publique des Hôpitaux de Marseille, and d’Ercole); the University of Medicine ofCarcopino, and d’Ercole); Clinical Investigationnal Institute of Health and Medical Researchealth, Direction de la Recherche Cliniquerseille, and the Department of Obstetrics and

Paris, Hôpital Robert Debré, Paris (Dr Renner),

pted Oct. 24, 2012.

ogie Obstétrique, Hôpital St Joseph,[email protected].

16/j.ajog.2012.10.882

se of oxytocin, operative delivery, man-al rotation, and maternal posturing be-

ore or during labor. But none of themad any proven efficacy in reducing per-istent OP position. Maternal posturings somewhat attractive because it is non-nvasive and theoretically harmless forhe fetus. In a recent Cochrane review,14

only a single study about the efficacy ofmaternal posturing during labor was ofsufficient quality to be included. Thistrial, using a single posture during labor(hands-and-knees), failed to demon-strate either any reduction of persistentOP at birth or improvement of maternalor neonatal outcomes.15 Two Chinesetrials (published in Chinese) have foundan increased rate of anterior rotation ofOP fetuses using lateral recumbent posi-tion during labor.16,17 These last 2 stud-ies were excluded from the Cochrane re-view14; no explanation was given aboutthe reason for such exclusion. However,with only these 3 trials, the presumedbenefit of maternal posturing during la-bor remains understudied and therefore

b

logistainoû,

atioic H, Made

cce

colce.

widely debated. Nevertheless, there is in

mailto:[email protected]

http://dx.doi.org/10.1016/j.ajog.2012.10.882

lslodIwrctirt

www.AJOG.org Obstetrics Research

France a growing interest in and use formaternal positioning during labor that issupported more on empirical knowledgethan on evidence-based medicine. Theaim of this study was to test the efficacyof maternal posture options during laboron prevention of persistent OP positionin order to reduce their maternal andneonatal morbidities.

MATERIALS AND METHODS

This randomized controlled trial tookplace in a tertiary care center maternityunit (Hôpital Nord, Marseille, France)from Jan. 5, 2009, through Jan. 25, 2011.Ethical approval was obtained from theCommittee for the Protection of Persons“Sud Méditérranée I.” Written informedconsent was obtained from each partici-pant before randomization. Eligible pa-tients were adult pregnant women (age�18 years) in labor at �36 weeks of ges-tation, with cervical dilatation of �3 cmand ruptured membranes, and with asingle fetus in cephalic OP position con-firmed by ultrasound examination. Ges-tational age calculation was based on theparticipant’s reported last menstrual pe-riod and fetal biometry at first-trimestersystematic ultrasound scan. After inclu-sion, participants were randomly as-signed to the intervention or the controlgroup. The randomization was made in

FIGURE 1Three-dimensional computer simul

A

Confrontation of fetal head with maternal pelvisDesbriere. Is maternal posturing during labor efficient in prev

permutated blocks of 4.

InterventionWhile randomized patients in the con-trol group adopted dorsal recumbentposition during labor, those in the inter-vention group had to adopt postures de-pending on the station of the fetal head.In both groups, if medically indicated(severe fetal heart rate abnormalities ormaternal hypotension), patients weretransiently placed in lateral recumbentposition for a short delay (�10 minutes)and immediately returned to their desig-nated posture. Because pressures appliedto the fetal head change as it progressesinto the pelvis, we postulated that mater-nal position should be adjusted to thedifferent stages of labor. Three differentmaternal postures were chosen after3-dimensional computer simulation andanalysis of theoretical rotation mecha-nism by one of the authors (J.-P.R.) us-ing 3-dimensional simulation software(Carrara 7 Pro; DAZ 3D Editor, Inc.Draper, Lake City, UT) (Figure 1). Pos-ture 1 was used in patients with fetal headstation between -5 and -3 (Figure 2, A)and corresponded to hands-and-kneesposture with possible support on a bal-loon at shoulder level. The expected goalof this posture was to move the fetusaway from the maternal spine to facili-tate its global rotation, assuming that thephysical confrontation of fetal spine withmaternal spine convexity and psoasmuscle in maternal recumbent position

on to analyze theoretical rotation me

B

spine at different levels of fetal head station; A,ng persistent occiput posterior position? Am J Obstet Gynecol

restricts its flexion (Figure 1, A). Patients a

JANUARY 2013 Ameri

with fetal head station between -2 and 0were positioned in posture 2 (Figure 2,B). Thus, patients were positioned instrict lateral recumbent position on thesame side of the fetal spine (eg, left ma-ternal lateral position for left fetal spine)with folded inferior leg and upper leg po-sitioned in the axis of the body. In thisposition, the maternal pelvic inlet wasoblique with the highest iliac crest lo-cated on the lower side (ie, the side of thepatient that is lying on the bed). The aimof this posture was to induce the flexionof the fetal head by confronting the fetalocciput to the maternal sacro-iliac jointand delay contact of the forehead withthe contralateral pubis allowing for com-plete flexion and thus provoke anteriorrotation (Figure 1, B). Finally, posture 3was used in patients with fetal head sta-tion �0 (Figure 2, C). It consisted of aateral recumbent position on the sameide of the fetal spine, with the inferioreg lying in the axis of the body and thether leg folded at an approximately 90-egree angle with the use of a leg support.n this position, the maternal pelvic inletas orientated in the exact opposite di-

ection than in posture 2. The aim was toonfront the fetal forehead with the leva-or ani and to therefore induce the flex-on of the fetal head, supposing that theotation of the fetal head would lead tohe anterior rotation of fetal shoulders

anism of fetal head

C

tween -5 and -3; B, between -2 and 0; C, �0..

ati ch

and beenti 2013

nd trunk (Figure 1, C).

can Journal of Obstetrics & Gynecology 60.e2

Tawdo

Research Obstetrics www.AJOG.org

A simplified and illustrated protocolwith a flow chart and detailed descrip-tions was available in the labor ward tohelp caregivers. Regardless of the timingof inclusion, the posture was maintainedas long as the fetal occiput remainedposterior and the patient tolerated it.The maternal posture was subsequentlyadapted to the evolution of the fetalhead station. Because ultrasonographyhas been demonstrated to be the goldstandard for the diagnosis of fetalpresentation,10-12,18,19 an ultrasono-graphic control of the fetal presentationwas performed every hour throughoutthe labor until anterior rotation of thefetal occiput was achieved. Patients whohad achieved anterior rotation werethen asked to adopt dorsal recumbentposition.

Outcome measuresWe considered that the primary out-comes had to be: (1) fetal head positionat delivery for spontaneous deliveries;and (2) fetal head position immediatelybefore instrumental delivery or cesareansection for operative deliveries. For allpatients who achieved vaginal spontane-ous delivery, the midwife or the obstetri-cian in charge of the delivery systemati-cally recorded the exact type of fetal headpresentation observed at the time of vag-inal delivery. In cases of operative deliv-ery, the fetal head position was recordedby means of ultrasonography immedi-ately before the instruments (either spat-ulas or vacuum) were applied. If a cesar-ean delivery was performed, the fetalhead presentation was confirmed by ul-trasonography immediately before ce-sarean section. As secondary outcomes,length of labor, length of pushing, oper-ative deliveries, cesarean sections, peri-neal lacerations (Anglo-Saxon classifica-tion), and neonatal morbidity (5- and10-minute Apgar scores, umbilical arte-rial pH) were systematically recorded.Maternal characteristics were collec-ted to verify the comparability of the2 groups: age, parity, gestational age,height, and initial and final weight. Fi-nally, factors that could have had an im-pact on head presentation were also re-
corded for analysis: analgesia, position of
60.e3 American Journal of Obstetrics & Gynecolog

placenta, spontaneous or induced labor,and oxytocin use.

Sample sizeThe sample size calculation was based ona previous nonrandomized pilot studyperformed in our maternity ward (datanot published) and relied on the as-

FIGURE 2Postures used during the trial

A, Postures used in patients with fetal head stationDesbriere. Is maternal posturing during labor efficient in prevGynecol 2013.

sumption that 60% of the control group c

y JANUARY 2013

would rotate from OP to occiput ante-rior13 vs 85% in the intervention group.

o achieve a 90% powered study with sett 0.001, we calculated that 202 patientsere required to be included and ran-omized. To compensate for any sec-ndary exclusion, we arbitrarily in-

between -5 and -3; B, between -2 and 0; C, �0.ng persistent occiput posterior position? Am J Obstet

; A,enti

reased this number by 10%; inclusion

pftpsturrsgcpw

Mzp


and randomization of 220 patients wastherefore required.

Statistical analysisStatistical analysis was performed usingsoftware (PASW Statistics, version17.0.2; IBM Corp, Armonk, NY). Dataare expressed as mean � SEM or medianwith interquartile interval. Groups werecompared using the �2 or Fisher exacttest for categorical characteristics, andusing the Student t test or Mann-Whit-ney U test for continuous ones, as appro-

riate. A multivariate analysis was per-ormed using a logistic regression modelo estimate risk factors for persistent OPosition. Variables that were found to beignificantly associated with outcome oro be marginally significant (P � .10) innivariate analysis, or that had clinicalelevance, were included in the logisticegression model. Calibration was as-essed using the Hosmer-Lemeshowoodness-of–fit test to evaluate the dis-repancy between observed and ex-ected values. A 2-sided P value � .05

FIGURE 3Flow of participants through variou

Inclurandomiz

(n=

Control group (n = 110) Deviation from protocol: manual rotation (n = 2)

Analysis, intention to treat

(n = 110)

Desbriere. Is maternal posturing during labor efficient in prevGynecol 2013.

as considered statistically significant.

ain outcome measure was analy-ed according to the intention-to-treatrinciple.

RESULTSPatientsOver 2 years, 220 women were prospec-tively included and randomized, ofwhom 110 were assigned to the interven-tion group and 110 to the control group.Figure 3 shows the flow of participantsthroughout the trial. No patient was sec-ondarily excluded from the study. Twopatients in the control group underwentsuccessful manual rotation immediatelybefore instrumental delivery and–there-fore considered as having persistent OPposition–they were not excluded fromthe study because we chose an intention-to-treat protocol. No deviation of proto-col occurred in the intervention group.Table 1 summarizes the baseline charac-teristics of the 2 groups. Except for cer-vical dilatation at the time of inclusion,the groups were comparable for gesta-

tages of trial

and women 0)

Intervention group (n = 110)

No deviation from protocol

Analysis, intention to treat

(n = 110)

ng persistent occiput posterior position? Am J Obstet

tional age, initial and final body mass in-

JANUARY 2013 Ameri

dex (BMI), parity, placental insertion,use of induction of labor and of epiduralanalgesia, and neonatal weight. In the in-tervention group, the majority of pa-tients (86/110; 78.2%) were includedwhen the fetal head station was between-2 and 0 cm, and then were recom-mended to adopt posture 2. Postures 1and 3 were used in 13.6% (15/110) and8.2% (9/110), respectively. No patienthad to adopt all 3 positions, as all womenwho adopted posture 1 had their fetusesrotate from OP to occipitoanterior be-fore they had to adopt posture 3. No sta-tistically significant differences were ob-served between the intervention andcontrol groups regarding the mode ofdelivery (Table 2). Operative deliverywas performed in 41 cases: 26 spatulas20

and 15 vacuums. Indications for opera-tive delivery were inadequate expulsiveefforts in 22 cases, nonreassuring fetalheart tracing in 18 cases, and maternalcontraindications to expulsive efforts in1 case. Forty patients underwent a cesar-ean section. Indications for cesarean sec-tion were: failure to progress beforecomplete dilatation in 24 cases (21 asso-ciated with persistent OP), failure toprogress at full dilatation in 9 cases (6associated with persistent OP), nonreas-suring fetal heart tracing in 6 cases, andbrow presentation in 1 case. Indicationsfor operative delivery or cesarean sectionwere not statistically different betweenthe 2 groups.

Main outcomeIn the intervention group, 24 (21.8%)patients were diagnosed with persistentOP position compared to 26 (23.6%) inthe control group (P � .75) (Table 3).When considering each mode of deliv-ery, no statistical difference between the2 groups regarding fetal head position atbirth or immediately before operativedelivery or cesarean section was ob-served (Table 2). In the control group,compared to spontaneous deliveries,persistent OP position was significantlymore often observed immediately beforeoperative delivery: 2 (2.8%) vs 7(33.3%), respectively (P � .001), andwas also more often observed immedi-ately before cesarean section than imme-

s s

deded22

enti

diately before operative delivery: 17


ubopmc


(89.5%) vs 7 (33.3%), respectively (P �.003). The same differences were ob-served in the intervention group: 4(5.8%) vs 5 (25%), respectively (P �.004), and 15 (71.4%) vs 5 (25%), respec-tively (P � .03).

Factors identified with significant andindependent impact on the anteriorrotation of the fetal headIn multivariable analysis, maternal BMIand parity were found to be independentfactors significantly associated with an-terior rotation of the fetal head duringlabor. For BMI, the adjusted odds ratio(AOR) was 0.94; 95% confidence inter-val (CI), 0.88 – 0.998; P � .045 (Table 4).Our results showed that a 1-U increase inBMI was associated with a 6% decreaseof the probability of an anterior rotationof fetal head. For women with parity �2,

TABLE 1Patient characteristics

CharacteristicInterventio(n � 110)

Maternal age, y 27.8 � 0...................................................................................................................

BMI..........................................................................................................

Initial 23.7 � 0..........................................................................................................

At time of delivery 28.6 � 0...................................................................................................................

Parity..........................................................................................................

Nullipara 69 (62.7)..........................................................................................................

1 23 (20.9)..........................................................................................................

�2 18 (16.4)...................................................................................................................

Gestational age, wk 39.4 � 0...................................................................................................................

Placental insertion..........................................................................................................

Anterior 49 (44.5)..........................................................................................................

Posterior 47 (42.8)..........................................................................................................

Others 14 (12.7)...................................................................................................................

Labor..........................................................................................................

Spontaneous 82 (74.5)..........................................................................................................

Induced 28 (25.5)...................................................................................................................

Median cervical dilatationat time of inclusion, cm

6.26

...................................................................................................................

Epidural analgesia 103 (93.6)...................................................................................................................

Birthweight, g 3466.2 � 4...................................................................................................................

Data are expressed as mean � SEM or n (%).BMI, body mass index.

Desbriere. Is maternal posturing during labor efficient in pGynecol 2013.

the AOR was 11.73; 95% CI, 1.48 –92.81;

60.e5 American Journal of Obstetrics & Gynecolog

P � .02, when compared to nulliparas(Table 4).

Obstetrical and neonatal outcomesBoth groups were comparable in termsof duration of first and second stage oflabor, oxytocin use, cervical dilatation orstation of fetal head at epidural place-ment, duration of maternal pushing,rates of episiotomy or perineal tears, andneonatal morbidity (Table 5). Only 1neonatal trauma (a scalp injury after vac-uum-assisted delivery) was reported inthe control group.

COMMENTIn France, interest for maternal position-ing during labor has been growing overthe last decade. However, because of the

roup Control group(n � 110) P value

28.9 � 0.51 .180..................................................................................................................

..................................................................................................................

24.1 � 0.49 .482..................................................................................................................

28.2 � 0.75 .680..................................................................................................................

..................................................................................................................

62 (56.4) .579..................................................................................................................

29 (26.4)..................................................................................................................

19 (17.3)..................................................................................................................

39.4 � 0.10 .950..................................................................................................................

..................................................................................................................

61 (55.4) .367..................................................................................................................

39 (35.5)..................................................................................................................

10 (9.1)..................................................................................................................

..................................................................................................................

81 (73.6) .878..................................................................................................................

29 (26.4)..................................................................................................................

5.68 .046

..................................................................................................................

105 (95.5) .553..................................................................................................................

9 3403.13 � 44.56 .300..................................................................................................................

nting persistent occiput posterior position? Am J Obstet

lack of genuine evidence, such manage-

y JANUARY 2013

ment only relies on personal beliefs andempirical practice. In a recent Cochranereview, authors estimated that only 1study evaluating this intervention dur-ing labor was of sufficient methodologi-cal quality to be included.14 This study,

sing a single type of posture during la-or (hands-and-knees), failed to dem-nstrate any benefit in the reduction ofersistent OP at birth or any improve-ent of maternal or neonatal out-

omes.15 Accordingly, the Cochranereview concluded that further randomi-zed trials were required to determinewhether encouraging postures during la-bor had any effect on the progress and/oroutcome of labor. The authors addedthat outcomes to be evaluated should bethe measure of pain experienced duringlabor, duration of labor, method of de-livery, baby’s condition, and maternalsatisfaction, and that the assessment offetal position by ultrasound would en-hance the reliability of these results.14

Our randomized controlled trial pro-vides an answer to the Cochrane con-cerns regarding clinical research on thatspecific topic.

Results from this prospective random-ized trial showed that a policy of mater-nal posturing for fetal OP position dur-ing labor had no significant effect on thefetal head rotation to the anterior posi-tion (P � .75) and whatsoever the modeof delivery (Table 2). Such finding is ofmajor clinical interest, as identificationof interventions currently used in prac-tice that do not have a beneficial effect onoutcome is important. Thus, for sponta-neous delivery the rate of persistent OPwas 5.8% in the intervention group vs2.8% in the control group (P � .44). Forassisted delivery the rate of persistent OPwas 10% in the intervention group vs14.3% in the control group (P � 1).Moreover, no significant difference wasobserved between the intervention andcontrol groups regarding the mode ofdelivery, duration of labor, use of oxyto-cin, induction of labor, use of epiduralanalgesia, cervical dilatation at epiduralplacement, duration of pushing, episiot-omy, perineal tear, Apgar score, neonatalacidemic cord blood gas concentrations,or admission to neonatal intensive care

n g

.64.........

.........

.47.........

.57.........

.........

.........

.........

.........

.10.........

.........

.........

.........

.........

.........

.........

.........

.........

.........

1.2.........

reve

unit (Table 5). One could consider that

tso(eps

ar1sfdb[fsaaerdsralPsfgrd


the difference reported in the mean valueof the cervical dilatation observed be-tween the 2 groups at the time of pa-tients’ inclusion could have potentiallybiased our results (Table 1). However,we believe such statistical difference isnot clinically relevant and results onlyfrom the subjectivity and variability ofclinical evaluation of cervical dilatation.Finally, our results are consistent withthe only other randomized controlledtrial that has been published to date. Us-ing a single hands-and-knees positionduring labor, this previous trial failed todemonstrate any significant differenceon maternal and neonatal outcomes be-

TABLE 2Mode of delivery and fetal head po

VariableInterven(n � 110

Spontaneous deliveries 69 (62.7)..........................................................................................................

OA 65 (94.2)..........................................................................................................

OP 4 (5.8)...................................................................................................................

Operative vaginal deliveries 20 (18.2)...................................................................................................................

Fetal head position beforeoperative delivery

..........................................................................................................

OA 15 (75)..........................................................................................................

OP 5 (25)...................................................................................................................

Fetal head position at birth..........................................................................................................

OA 18 (90)..........................................................................................................

OP 2 (10)...................................................................................................................

CS deliveries 21 (19.1)...................................................................................................................

Fetal head position before CS..........................................................................................................

OA 6 (28.6)..........................................................................................................

OP 15 (71.4)...................................................................................................................

Data are expressed as n (%).CS, cesarean section; OA, occipito anterior; OP, occipito post

Desbriere. Is maternal posturing during labor efficient in pGynecol 2013.

TABLE 3Primary outcome according to stud

VariableIntervent(n � 110

Anterior rotation 86 (78.2)...................................................................................................................

Persistent posterior position 24 (21.8)...................................................................................................................

Data are expressed as n (%).

Desbriere. Is maternal posturing during labor efficient in p
Gynecol 2013.
tween the intervention and controlgroups.15

In our study, the rate of epidural anal-gesia was not significantly different be-tween the intervention and controlgroups (93.6% vs 95.5%, P � .55), buthese rates were higher than the one ob-erved among all patients managed inur maternity during the same period72%). The finding of a higher rate ofpidural use in women with the fetal OPosition has been documented in othertudies.4,5 Currently, data are not suffi-

cient to definitely conclude whether epi-dural analgesia may contribute to persis-tent OP position, or whether women

ion, according to study group

group Control group(n � 110) P value

70 (63.6) .889..................................................................................................................

68 (97.1) .441..................................................................................................................

2 (2.8)..................................................................................................................

21 (19.1) .965..................................................................................................................

..................................................................................................................

14 (66.7) .558..................................................................................................................

7 (33.3)..................................................................................................................

..................................................................................................................

18 (85.7) 1..................................................................................................................

3 (14.3)..................................................................................................................

19 (17.3) .727..................................................................................................................

..................................................................................................................

2 (10.5) .241..................................................................................................................

17 (89.5)..................................................................................................................


roup

group Control group(n � 110) P value

84 (76.4) .748..................................................................................................................

26 (23.6)..................................................................................................................


JANUARY 2013 Ameri

with OP position experience more painduring labor and therefore request theuse of epidural analgesia more often.21-23

However, we may wonder about the epi-dural and persistent OP causality issue.In a prospective cohort study of 1562nulliparous women in labor, Liebermanet al22 found that epidural analgesia wasssociated with a 4-fold increase in theisk of OP at delivery (AOR, 4.0; 95% CI,.4 –11.1) by means of a logistic regres-ion analysis. The same authors alsoound that women with an OP fetus atelivery did not report more painful la-ors at enrollment (mean pain score 4.9�2.8] for OP at delivery vs 5.2 [�2.6]or not OP at delivery, P � .2).22 In ourtudy, we were not able to test if epiduralnalgesia was specifically associated withn increase in fetal OP position at deliv-ry since only 12 patients of 220 did noteceive epidural analgesia for pain reliefuring labor. Nevertheless, our resultshowed that cervical dilatation at epidu-al placement was not associated withnterior rotation of the fetal head duringabor (AOR, 1.14; 95% CI, 0.89 –1.47;

� .295) (Table 4). This finding isomewhat consistent with the fact that,or women in labor, early epidural anal-esia is not accompanied by an increasedate of cesarean or instrumental vaginaleliveries.24 Interestingly, when com-

paring to patients who had deliveredspontaneously, we observed a progres-sive and significant increase of persistentOP position among patients who under-went operative deliveries and particu-larly among those who had a cesareansection (Table 2). These findings str-engthen the theory that malrotation offetal head is associated with increasedmaternal morbidity.4-6,8

In multivariable analysis, only mater-nal BMI and parity were found to be in-dependent factors associated with ante-rior rotation of the fetal head duringlabor. A similar finding has been previ-ously reported by Ponkey et al.5 In theircohort study, the proportion of womenwith persistent OP position at deliverywas nearly 2 times higher among nullip-aras (7.2%) than among multiparas(4%) (P � .001).5 To our knowledge, weare the first to show an effect of BMI on

sit

tion)

.........

.........

.........

.........

.........

.........

.........

.........

.........

.........

.........

.........

.........

.........

erior.

reve

y g

ion)

.........

.........

reve

the rotation of fetal head during labor.


Gynecol 2013.

Gynecol 2013.


60.e7 American Journal of Obstetrics & Gynecology JANUARY 2013

According to our findings, a 1-U increasein BMI is associated with a 6% decreaseof the probability of an anterior rotationof fetal head. This finding is not consis-tent with any other retrospective or co-hort studies on this subject, and must beconfirmed by other studies.

In conclusion, our study failed todemonstrate any maternal or neonatalbenefit to a policy of maternal posturingduring labor for OP position. We believethat such posture should not be imposedon women having an OP position duringlabor and that epidural analgesia shouldnot be delayed in nulliparous patients inlabor as its placement timing has no ef-fect on fetal head rotation or maternaland neonatal morbidities. As highlightedby Kariminia et al,25 identification of in-terventions currently used in practicethat do not have a beneficial effect onoutcome is important. Women who areadvised to adopt postures during labormay feel a sense of failure or shame ifthey do not follow that advice and mayalso find their confidence in their care-giver diminished if fetal head failed torotate despite properly following recom-mendations. Identification of a tech-nique that could effectively reduce therate of operative delivery by correctingthe fetal malpresentation and allowingfor normal descent and delivery of thefetus remains a challenge because itwould have the potential to reduce ma-ternal and neonatal morbidity and mor-tality. Recently, a protocol from theCochrane Database26 was publishedwith the objective of assessing the effectof prophylactic manual rotation forwomen with malposition in labor on themode of delivery and maternal and neo-natal outcomes. We believe that this pro-cedure is worth considering and evaluat-ing by means of randomized controlledtrials.

Clinical implicationsThis study proposed an evaluation of aposturing method to treat persistent OPposition, which is the most commonmalposition during labor and is associ-ated with maternal and neonatal mor-bidities. In all, 220 patients were ran-domized in 2 groups (postured or not)

TABLE 4Multivariable analysis: factors associatedwith anterior rotation of fetal head

Variable AOR 95% CI P value

Age 1.046 0.979–1.117 .187..............................................................................................................................................................................................................................................

BMI 0.936 0.877–0.998 .045..............................................................................................................................................................................................................................................

Labor (spontaneous vs induced) 0.501 0.240–1.045 .065..............................................................................................................................................................................................................................................

Cervical dilatation at epidural placement 1.144 0.889–1.470 .295..............................................................................................................................................................................................................................................

Parity � 0 1 — —..............................................................................................................................................................................................................................................

Parity � 1 0.979 0.445–2.154 .957..............................................................................................................................................................................................................................................

Parity �2 11.726 1.481–92.806 .020..............................................................................................................................................................................................................................................

AOR, adjusted odds ratio; BMI, body mass index; CI, confidence interval.

Desbriere. Is maternal posturing during labor efficient in preventing persistent occiput posterior position? Am J Obstet

TABLE 5Obstetric and neonatal outcomes according to study group

VariableIntervention group(n � 110)

Control group(n � 110) P value

Duration of labor, h.....................................................................................................................................................................................................................................

First stage 3.0 (1.425-4.70) 3.0 (1.5-4.0) .435.....................................................................................................................................................................................................................................

Second stage 1.0 (0.17-2.0) 0.8 (0.32-2.30) .666..............................................................................................................................................................................................................................................

Oxytocin use 96 (87.3) 103 (93.6) .108..............................................................................................................................................................................................................................................

Mean maximal dosage, mL/h 67.84 73.95 .267..............................................................................................................................................................................................................................................

Epidural analgesia..............................................................................................................................................................................................................................................

Cervical dilatation at placement 3.82 � 0.13 3.64 � 0.12 .317..............................................................................................................................................................................................................................................

Length of pushing, min 16.35 � 1.29 15.98 � 1.17 .830..............................................................................................................................................................................................................................................

Perineal tears.....................................................................................................................................................................................................................................

No tears 18 (20.2) 21 (23.1) .757.....................................................................................................................................................................................................................................

Episiotomy 27 (30.3) 28 (30.7).....................................................................................................................................................................................................................................

Lacerations 44 (49.5) 42 (46.2)............................................................................................................................................................................................................................

First degree 32 30 .532............................................................................................................................................................................................................................

Second degree 12 10............................................................................................................................................................................................................................

Third degree 0 1............................................................................................................................................................................................................................

Fourth degree 0 1..............................................................................................................................................................................................................................................

Apgar score.....................................................................................................................................................................................................................................

5 min 9.69 � 0.78 9.84 � 0.65 .121.....................................................................................................................................................................................................................................

10 min 9.90 � 0.37 9.95 � 0.28 .309..............................................................................................................................................................................................................................................

Umbilical arterial pH 7.278 � 0.075 7.279 � 0.067 .886..............................................................................................................................................................................................................................................

Hospitalization in NICU 6 (5.4) 3 (2.7) .498..............................................................................................................................................................................................................................................

Data are expressed as mean � SEM except for duration of labor expressed as median with interquartile range or n (%).NICU, neonatal intensive care unit.

Desbriere. Is maternal posturing during labor efficient in preventing persistent occiput posterior position? Am J Obstet

and the primary outcome was fetal


head position at delivery. A policy ofmaternal posturing for the manage-ment of OP position during labor didnot lead to maternal or neonatal bene-fit. We believed that no posture shouldbe imposed on women with OP posi-tion during labor. f

REFERENCES1. Gardberg M, Tuppurainen M. Persistent oc-ciput posterior presentation–a clinical problem.Acta Obstet Gynecol Scand 1994;73:45-7.2. Gardberg M, Laakkonen E, Salevaara M. In-trapartum sonography and persistent occiputposterior position: a study of 408 deliveries. Ob-stet Gynecol 1998;91:746-9.3. Sizer AR, Nirmal DM. Occipitoposterior posi-tion: associated factors and obstetric outcomein nulliparas. Obstet Gynecol 2000;96:749-52.4. Fitzpatrick M, McQuillan K, O’Herlihy C. Influ-ence of persistent occiput posterior position ondelivery outcome. Obstet Gynecol 2001;98:1027-31.5. Ponkey SE, Cohen AP, Heffner LJ, et al. Per-sistent fetal occiput posterior position: obstetricoutcomes. Obstet Gynecol 2003;101:915-20.6. Senecal J, Xiong X, Fraser WD. Effect of fetalposition on second-stage duration and laboroutcome. Obstet Gynecol 2005;105:763-72.7. Cheng YW, Shaffer BL, Caughey AB. Theassociation between persistent occiput poste-rior position and neonatal outcomes. ObstetGynecol 2006;107:837-44.8. Cheng YW, Hubbard A, Caughey AB, et al.The association between persistent fetal oc-ciput posterior position and perinatal out-comes: an example of propensity score and co-variate distance matching. Am J Epidemiol
2010;171:656-63.
9. Badawi N, Kurinczuk JJ, Keogh JM, et al.Intrapartum risk factors for newborn encepha-lopathy: the Western Australian case-controlstudy. BMJ 1998;317:1554-8.10. Sherer DM, Miodovnik M, Bradley KS, et al.Intrapartum fetal head position I: comparisonbetween transvaginal digital examination andtransabdominal ultrasound assessment duringthe active stage of labor. Ultrasound Obstet Gy-necol 2002;19:258-63.11. Sherer DM, Miodovnik M, Bradley KS, et al.Intrapartum fetal head position II: comparisonbetween transvaginal digital examination andtransabdominal ultrasound assessment duringthe second stage of labor. Ultrasound ObstetGynecol 2002;19:264-8.12. Akmal S, Kametas N, Tsoi E, et al. Compar-ison of transvaginal digital examination with in-trapartum sonography to determine fetal headposition before instrumental delivery. Ultra-sound Obstet Gynecol 2003;21:437-40.13. Akmal S, Tsoi E, Howard R, et al. Investiga-tion of occiput posterior delivery by intrapartumsonography. Ultrasound Obstet Gynecol2004;24:425-8.14. Hunter S, Hofmeyr GJ, Kulier R. Hands andknees posture in late pregnancy or labor for fetalmalposition (lateral or posterior). Cochrane Da-tabase Syst Rev 2007;4:CD001063.15. Stremler R, Hodnett E, Petryshen P, et al.Randomized controlled trial of hands-and-knees positioning for occipitoposterior positionin labor. Birth 2005;32:243-51.16. Wu X, Fan L, Wang Q. Correction of oc-cipito-posterior by maternal postures during theprocess of labor [in Chinese]. Zhonghua FuChan Ke Za Zhi 2001;36:468-9.17. Ou X, Chen X, Su J. Correction of occipito-posterior position by maternal posture duringthe process of labor [in Chinese]. Zhonghua Fu
Chan Ke Za Zhi 1997;32:329-32.
JANUARY 2013 Ameri

18. Hidar S, Choukou A, Jerbi M, et al. Clinicaland sonographic diagnosis of occiput posteriorposition: a prospective study of 350 deliveries[in French]. Gynecol Obstet Fertil 2006;34:484-8.19. Akmal S, Tsoi E, Kametas N, et al. Intrapar-tum sonography to determine fetal head posi-tion. J Matern Fetal Neonatal Med 2002;12:172-7.20. Boucoiran I, Valerio L, Bafghi A, et al. Spat-ula-assisted deliveries: a large cohort of 1065cases. Eur J Obstet Gynecol Reprod Biol2010;151:46-51.21. Le Ray C, Carayol M, Jaquemin S, et al. Isepidural analgesia a risk factor for occiputposterior or transverse positions during la-bor? Eur J Obstet Gynecol Reprod Biol2005;123:22-6.22. Lieberman E, Davidson K, Lee-Paritz A, etal. Changes in fetal position during labor andtheir association with epidural analgesia. ObstetGynecol 2005;105:974-82.23. Thorp JA, Hu DH, Albin RM, et al. The effectof intrapartum epidural analgesia on nulliparouslabor: a randomized, controlled, prospectivetrial. Am J Obstet Gynecol 1993;169:851-8.24. Wassen MM, Zuijlen J, Roumen FJ, et al.Early versus late epidural analgesia and risk ofinstrumental delivery in nulliparous women: asystematic review. BJOG 2011;118:655-61.25. Kariminia A, Chamberlain ME, Keogh J, etal. Randomized controlled trial of effect ofhands and knees posturing on incidence of oc-ciput posterior position at birth. BMJ 2004;328:490.26. Phipps H, de Vries B, Hyett J, Osborn DA.Prophylactic manual rotation for fetal malposi-tion to reduce operative delivery (protocol). Co-
chrane Database Syst Rev 2011;CD009228.

Documents

Maternal Posturing During Labor