Format for Mini-CAT
Jeanine Alokush, Maria Barak, Christopher Inderjit, Mariyanthie Linaris, and Chaya Wertman
Clinical Question: Please state this as briefly as possible based on the scenario provided
Does non-lithotomy positioning reduce the incidence of labor complications in women during the second stage of labor compared to lithotomy positioning?
PICO Question:
Does non-lithotomy positioning reduce the incidence of labor complications in women during the second stage of labor compared to lithotomy positioning?
Identify the PICO elements (Recalling that some questions do not have all the elements)
|
P |
I | C |
O |
| Women in labor | Non-lithotomy position | Lithotomy position | Instrumental delivery |
| Childbirth | Upright position | Use of stirrups | Forceps delivery |
| Squatting position | Supine position | Vacuum delivery | |
| Non-stirrup position | Perineal tears | ||
| Lateral birthing position |
|
Cesarean section | |
| Episiotomy |
Search Strategy:
Outline the terms used, databases or other tools used, how many articles returned, and how you selected the final articles to base your CAT on
Pubmed:
- Birthing position outcomes → Best match → 55 results
- Squatting labor position → Best match → 118 results
- Labor position instrumental delivery → Best match → 120 results
- Upright delivery instrumental delivery → Best match → 17 results
Cochrane:
- Evidence of birthing positions → Best match → 8,112 results
Final articles were chosen based on the inclusion of the following factors: quality of the study, preference for systematic reviews and randomized control trials, comparison of lithotomy/supine position to other positions, number of participants, and relevance to the clinical scenario.
Articles Chosen for Inclusion (please copy and paste the abstract with link):
- A RANDOMIZED TRIAL OF BIRTHING WITH AND WITHOUT STIRRUPS
Marlene M. CORTON, M.D., Janice C. LANKFORD, CNM, Rebecca AMES, CNM, Donald D. MCINTIRE, Ph.D., James M. ALEXANDER, M.D., and Kenneth J. LEVENO, M.D.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3409565/?log$=activity
OBJECTIVE
To determine if bed delivery without stirrups reduces the incidence of perineal lacerations compared to delivery in stirrups.
STUDY DESIGN
In this randomized trial we compared bed delivery without stirrups to delivery in stirrups in nulliparous women. The primary outcome was any perineal laceration (first- through fourth-degree).
RESULTS
108 women were randomized to delivery without stirrups and 106 to stirrups. A total of 82 (76%) women randomized to no stirrups sustained perineal lacerations compared to 83 (78%) in women allocated to stirrups, p = .8. There was no significant difference in the severity of lacerations or in obstetric outcomes such as prolonged second stage of labor, forceps delivery, or cesarean birth. Similarly, infant outcomes were unaffected.
CONCLUSION
Our results do not incriminate stirrups as a cause of perineal lacerations. Alternatively, our findings of no difference in perineal lacerations suggest that delivering in bed without stirrups confers no advantages nor disadvantages.
This article was chosen because it is a randomized control trial that is relatively recent (2012). It directly addresses our research question and measures many outcomes in addition to the primary outcome of perineal lacerations.
- Position in the second stage of labour for women without epidural anaesthesia.
Gupta JK, et al. Cochrane Database Syst Rev. 2017.
https://www.ncbi.nlm.nih.gov/m/pubmed/28539008/?i=2&from=the%20evidence%20on%20birthing%20positions
BACKGROUND
For centuries, there has been controversy around whether being upright (sitting, birthing stools, chairs, squatting, kneeling) or lying down (lateral (Sim’s) position, semi-recumbent, lithotomy position, Trendelenburg’s position) have advantages for women giving birth to their babies. This is an update of a review previously published in 2012, 2004 and 1999.
OBJECTIVES
To determine the possible benefits and risks of the use of different birth positions during the second stage of labour without epidural anaesthesia, on maternal, fetal, neonatal and caregiver outcomes.
SEARCH METHODS
We searched Cochrane Pregnancy and Childbirth’s Trials Register (30 November 2016) and reference lists of retrieved studies.
SELECTION CRITERIA
Randomised, quasi-randomised or cluster-randomised controlled trials of any upright position assumed by pregnant women during the second stage of labour compared with supine or lithotomy positions. Secondary comparisons include comparison of different upright positions and the supine position. Trials in abstract form were included.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed trials for inclusion and assessed trial quality. At least two review authors extracted the data. Data were checked for accuracy. The quality of the evidence was assessed using the GRADE approach.
MAIN RESULTS
Results should be interpreted with caution because risk of bias of the included trials was variable. We included eleven new trials for this update; there are now 32 included studies, and one trial is ongoing. Thirty trials involving 9015 women contributed to the analysis. Comparisons include any upright position, birth or squat stool, birth cushion, and birth chair versus supine positions.In all women studied (primigravid and multigravid), when compared with supine positions, the upright position was associated with a reduction in duration of second stage in the upright group (MD -6.16 minutes, 95% CI -9.74 to -2.59 minutes; 19 trials; 5811 women; P = 0.0007; random-effects; I² = 91%; very low-quality evidence); however, this result should be interpreted with caution due to large differences in size and direction of effect in individual studies. Upright positions were also associated with no clear difference in the rates of caesarean section (RR 1.22, 95% CI 0.81 to 1.81; 16 trials; 5439 women; low-quality evidence), a reduction in assisted deliveries (RR 0.75, 95% CI 0.66 to 0.86; 21 trials; 6481 women; moderate-quality evidence), a reduction in episiotomies (average RR 0.75, 95% CI 0.61 to 0.92; 17 trials; 6148 women; random-effects; I² = 88%), a possible increase in second degree perineal tears (RR 1.20, 95% CI 1.00 to 1.44; 18 trials; 6715 women; I² = 43%; low-quality evidence), no clear difference in the number of third or fourth degree perineal tears (RR 0.72, 95% CI 0.32 to 1.65; 6 trials; 1840 women; very low-quality evidence), increased estimated blood loss greater than 500 mL (RR 1.48, 95% CI 1.10 to 1.98; 15 trials; 5615 women; I² = 33%; moderate-quality evidence), fewer abnormal fetal heart rate patterns (RR 0.46, 95% CI 0.22 to 0.93; 2 trials; 617 women), no clear difference in the number of babies admitted to neonatal intensive care (RR 0.79, 95% CI 0.51 to 1.21; 4 trials; 2565 infants; low-quality evidence). On sensitivity analysis excluding trials with high risk of bias, these findings were unchanged except that there was no longer a clear difference in duration of second stage of labour (MD -4.34, 95% CI -9.00 to 0.32; 21 trials; 2499 women; I² = 85%).The main reasons for downgrading of GRADE assessment was that several studies had design limitations (inadequate randomisation and allocation concealment) with high heterogeneity and wide CIs.
AUTHORS’ CONCLUSIONS
The findings of this review suggest several possible benefits for upright posture in women without epidural anaesthesia, such as a very small reduction in the duration of second stage of labour (mainly from the primigravid group), reduction in episiotomy rates and assisted deliveries. However, there is an increased risk blood loss greater than 500 mL and there may be an increased risk of second degree tears, though we cannot be certain of this. In view of the variable risk of bias of the trials reviewed, further trials using well-designed protocols are needed to ascertain the true benefits and risks of various birth positions.
PMID 28539008 [Indexed for MEDLINE] PMCID PMC6484432
This article was used because it included a systematic review of a series of randomized controlled trial including 9,015 women comparing upright and lying down birth positions. In addition, the study was recently published in 2017. This study aims to reevaluate previous studies conducted in the past.
- Childbirth in Squatting Position
Ayesha Nasir, Razia Korejo, K.J. Noorani
https://www.jpma.org.pk/PdfDownload/1040
OBJECTIVE
To assess the risks and benefits of squatting position during second stage of labour. and its comparison with the supine position.
METHODS
The study was conducted at the Department of Obstetrics and Gynaecology, Jinnah Postgraduate Medical Centre, Karachi from 1st January 1999 to 31st January 2000. A total of two hundred patients of similar ante partum, intrapartum and socio-economic conditions were selected. Only patients of gestation more than 37 weeks, presenting in active labour with cephalic presentation were included. Patients with multiple gestation, malpresentation, previous scar, maternal fever and prenatal diagnosed fetal malformation were excluded from the study. Random selection was done after informed consent and alternately divided into two groups A and B. Both groups were ambulatory during first stage of labour. In second stage, group-A adopted the squatting position, while group-B remained supine in lithotomy position. The third stage of labour in both the groups was conducted in the supine position.
RESULTS
There was no difference in the application of episiotomies in both groups, however extension of the episiotomy occurred in 7% patients of the non-squatting group(P<0.05). Para urethral tears occurred in 5% patients in squatting group, but all occurred in patients who were not given an episiotomy. Second degree, and third degree perineal tears occurred in 9% patients in the non-squatting group but none in the squatting group (P<0.05). Forceps application was also significantly less in group-A 11% and 24% in group-B (P<0.05).There were two cases of shoulder dystocia in group B but none in the group-A. During the Third stage of labour there were no cases of retained placenta in group A but there were 4% cases of retained placenta and 1% case of postpartum haernorrhage of more than 500ml due to atony of the uterus in group-B. One patient in the non-squatting position had to have a caesarean section due to persistent occipito posterior position. There was no significant difference in the APGAR scores, foetal heart rate patterns or requirement of neonatal resuscitation.
CONCLUSION
It appears that squatting position may result in less instrumental deliveries, extension of episiotomies and perineal tears (JPMA 57:19;2007).
This article was chosen because it examines a great number of factors influenced by birthing position between two nearly matched (according to the authors) samples) on both the mother and neonate. Compared to some other articles, it also had more participants in each group, lending more power and reliability to the study.
- A meta-analysis of upright positions in the second stage to reduce instrumental deliveries in women with epidural analgesia
CHRISTINE L. ROBERTS, CHARLES S. ALGERT , CAROLYN A. CAMERON AND SIRANDA TORVALDSEN
https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1111/j.0001-6349.2005.00786.x
BACKGROUND
Epidural analgesia is associated with an increased risk of instrumental delivery. We, in this study, present a systematic review in order to assess the effectiveness of maintaining an upright position during the second stage of labor to reduce instrumental deliveries among women choosing epidural analgesia. The study population included women with uncomplicated pregnancies at term with epidural analgesia established in the first stage of labor.
METHODS
We searched MEDLINE, EMBASE, and CINAHL databases and the Cochrane Trials Register up to July 2003 and cross-checked the reference lists of published studies. Trial eligibility and outcomes were pre-specified. Group tabular data were obtained for each trial and were analyzed by using meta-analytic techniques.
RESULTS
Only two studies were included with data on 281 women (166 upright and 115 recumbent). Upright positions in the second stage were associated with a non-significant reduction in the risk of both instrumental delivery (relative risk (RR) ¼ 0.77, 95% confidence interval (CI) ¼ 0.46–1.28) and cesarean section (RR ¼ 0.57, 95% CI ¼ 0.28–1.16). Both studies reported a statistically significant reduction in labor duration associated with upright positions. Data on other outcomes, including perineal trauma, postpartum hemorrhage, maternal satisfaction, and infant well-being, were insufficient.
CONCLUSIONS
There were insufficient data to show a significant benefit from upright positions in the second stage of labor for women who choose epidural or to evaluate safety aspects. However the magnitude of the reductions in instrumental delivery and cesarean section warrants an adequately powered randomized, controlled trial to fully evaluate the practice of upright positions in the second stage for women with an epidural.
I chose this article because it is MEDLINE indexed and it is a meta analysis of randomized control trials. Additionally, the topic is related to what my group was searching. Despite that the results were statistically insignificant and the study was done in another country, it allows us to get a good insight on what the recommendations maybe on upright position vs recumbent.
- Birth position, accoucheur, and perineal outcomes: informing women about choices for vaginal birth.
Shorten A1, Donsante J, Shorten B.
https://onlinelibrary.wiley.com/doi/pdf/10.1046/j.1523-536X.2002.00151.x
BACKGROUND
The literature is tentative in establishing links between birth position and perineal outcome. Evidence is inconclusive about risks and benefits of women’s options for birth position. The objective of this study was to gain further evidence to inform perinatal caregivers about the effect of birth position on perineal outcome, and to assist birth attendants in providing women with information and opportunities for minimizing perineal trauma.
METHODS
Data from 2891 normal vaginal births were analyzed. Descriptive statistics were obtained for variables of interest, and cross-tabulations were generated to explore possible relationships between perineal outcomes, birth positions, and accoucheur type. Logistic regression models were used to examine potential confounding and interaction effects of relevant variables.
RESULTS
Multiple regression analysis revealed a statistically significant association between birth position and perineal outcome. Overall, the lateral position was associated with the highest rate of intact perineum (66.6%) and the most favorable perineal outcome profile. The squatting position was associated with the least favorable perineal outcomes (intact rate 42%), especially for primiparas. A statistically significant association was demonstrated between perineal outcome and accoucheur type. The obstetrician group generated an episiotomy rate of 26 percent, which was more than five times higher than episiotomy rates for all midwife categories. The rate for tear requiring suture of 42.1 percent for the obstetric category was 5 to 7 percentage points higher than that for midwives. Intact perineum was achieved for 31.9 percent of women delivered by obstetricians compared with 56 to 61 percent for three midwifery categories.
CONCLUSION
Findings contribute to growing evidence that birth position may affect perineal outcome. Women’s childbirth experiences should reflect decisions made in partnership with midwives and obstetricians who are equipped with knowledge of risks and benefits of birthing options and skills to implement women’s choices for birth. Further identification and recognition of the strategies used by midwives to achieve favorable perineal outcomes is warranted.
This article was chosen because it discussed a variety of birthing positions besides the usual lithotomy position. In addition, it discussed many different factors that can be affected by the birthing position of the mother, ultimately relating to the safety and better outcome of the mother after giving birth. Furthermore, the study had a good sample size and displayed the results clearly, which were significant.
Summary of the Evidence:
| Author (Date) | Level of Evidence | Sample/Setting
(# of subjects/ studies, cohort definition etc. ) |
Outcome(s) studied | Key Findings | Limitations and Biases |
| Roberts, C.,
Algert. C, Cameron, C Torvaldsen, S (2005) |
Meta-
analysis |
2 randomized control trials (Golara et al. & Karraz ) that included,
281 women |
The outcome studied was upright positions in the second stage to reduce instrumental deliveries in women with epidural analgesia compared to down side position
|
There were large, but statistically non‐significant, reductions in the risks of instrumental and cesarean deliveries for upright compared to recumbent positions in the second stage of labor. (results were considered inconclusive) | Small population size
Was studied in Australia
The definition of “upright” was different for each sample that was chosen
Karraz studied younger patients (mean age 27) , where Golara et al. study studied more older patients (mean age 30)
Trials in this meta analysis were not blinded, allowing for bias to occur if obstetricians that were reviewing the articles chose an article over others due to favorable findings |
| Nasir, A., Korejo, R., & Noorani, K. J. (2007) | Randomized Control Trial | 200 women with gestational age > 37 weeks with similar ante partum, intrapartum, and socioeconomic conditions presenting in active labor
Randomized into Group A (squatting position) and Group B (lithotomy position) |
Application/extention of episiotomies
Paraurethral tears
Perineal tears
Shoulder dystocia
Retained placenta
Postpartum hemorrhage
Forceps application (instrumental delivery)
Neonatal outcomes |
No significant difference in application of episiotomies (p = .48), but significant decrease in episiotomy extension (p = .007) in group A
No significant difference in incidence of paraurethral tears (p = .222)
Significantly fewer perineal tears in group A (p = .002)
No significant difference in shoulder dystocia (p = .25), retained placenta (p = .061 — trending toward significant), or postpartum hemorrhage (p = .5)
Significantly fewer instrumental deliveries in group A (p < .05)
Easiest to push in squatting position No significant difference in neonatal outcomes |
Small sample size
Conducted in Karachi, Pakistan, so the data might not be generalizable to patients in the United States
Does not differentiate the results between squatting specifically and other upright positions (like kneeling)
Data collected between 1999 and 2000, article published in 2007, so might be a bit outdated |
| Shorten A. , Donsante, J. , & Shorten, B.
(2002) |
Retrospective Cohort | -2891 normal vaginal births
-regional teaching hospital on new south wales, Australia -women were 13-45 years of age (mean=27 years) -mean duration of second stage of labor was slightly more than 30 minutes -midwives and obstetricians delivered about 1447/2981 births -nulliparous and multiparous women – Birthing positions included: lateral, all fours, kneeling, standing, and squatting. |
-perineal outcome: intact or graze/tear not sutured
-1st, 2nd, 3rd degree tears -labial tear -episiotomy
|
-the lateral position had the highest intact rate (66.6%) and also had below average episiotomy rates
-birthing position did affect rate of episiotomy for both nulliparas ( p < 0.005) and multiparas ( p < 0.001) -Similarly, significant effects were found for birth position on the risk of tears requiring suture, for both nulliparas ( p < 0.10) and multiparas (p < 0.001). -As for the odds of achieving an intact perineum, birth position was significant in the case of multiparas only (, p < 0.001).
|
-took place in Australia
-not everyone was birthed by same professional, some were birthed by midwives, obstetricians, other physicians, student midwife -from 2002. –Done in one hospital |
| Marlene M. CORTON, M.D., Janice C. LANKFORD, CNM, Rebecca AMES, CNM, Donald D. MCINTIRE, Ph.D., James M. ALEXANDER, M.D., and Kenneth J. LEVENO, M.D. Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
(2012)
|
RCT
|
took place in one of three labor and delivery units at parkland hospital
214 women randomized allocated to bed delivery without stirrups or with stirrups ( placed in stirrups once the fetal head visible) 108 women without 106 with stirrups 202 delivered vaginally
no difference in maternal age or BMI between the two groups race/ethnicity- was significantly different – white women overrepresented in no stirrups
|
Primary outcome: Any perineal lacerations first through fourth-degree graded as defined in the 23rd edition of williams obstetrics (determined after delivery of the infant and placenta, a second perineal exam done independently by a second midwife to increase precision of the description of laceration and minimize bias)
Secondary outcomes (obstetric outcomes, characteristics that might impact perineal lacerations for the two study groups are compared, variables that are risk factors for perineal laceration): – infant outcomes – severity of lacerations – prolonged second stage of labor – forceps delivery – cesarean birth – augmentation of labor with oxytocin
|
82 (76%) randomized to no stirrups – one or more perineal lacerations
83 (78%) randomized with stirrups – one or more perineal lacerations p=.8. Stirrups not significantly associated with lacerations.
no significant differences in the severity of perineal lacerations, infant outcomes, other obstetric outcomes measured related to birth with or without stirrups. no significant differences when combinations of lacerations were analyzed
Results adjusted for maternal race and ethnicity using logistic regression: stirrups use was not significantly associated with lacerations
There are no apparent advantages or disadvantages, especially in terms of perineal lacerations, when delivering in bed without stirrups
(although this study does not conclude that stirrup use is associated with more lacerations, it suggests that stirrups use may not be necessary, as there are no disadvantages to delivering without stirrups; study does not contradict our conclusion)
|
small size- 214
P values large = .8
Only done in one hospital
Does not include confidence intervals
White women overrepresented in the no stirrups group Only analyzed two positions
|
| Janesh K.Gupta, Akanksha Sood, G. Justus Hofmeyr, Joshua P. Vogel (2017) | RCT | -30 randomized control trials involving 9,015 women who gave birth without epidural anaesthesia
-Studies were conducted in hospital. 7 from the UK; 9 from Asian sub-continent; 5 from EU; 4 from America; 3 from Middle East; 1 from Cape Town; and 1 from New Zealand
|
-To determine the risk/benefit of different birth positions during second stage of labor without epidural anaesthesia.
-The study includes a comparison of different upright position and supine position. Birth positions include: 1) upright: sitting, birthing stools, chairs, squatting, and kneeling 2) lying down: Sim’s, semi-recombent, Trendelenburg’s or lithotomy position
|
-Overall reduction in duration of second stage of labor in the upright position by use of birth cushion.
-Fewer women had assisted delivery using forceps. Birth stools and birth chairs had no effect. -Women more likely to have blood loss 500ml or more.
|
-Funding Sources were not reported in the studies
-Blinding of participants, personnels and outcome examiners were not performed or unclear in the trial. Since blinding was not possible, negative or positive attitude of caregiver toward birth positions may influence result. -Heterogeneity meaning there was a very diverse content which resulted in inadequate randomization and design limitations – Wide Confidence Intervals
|
Conclusion(s):
While there is a good deal of conflict in previously published literature, most research illustrates that there is no significant advantage of lithotomy positioning over other positions.
A majority of research demonstrates some degree of improved maternal outcome in non-lithotomy positioning during the second stage of labor, including a lesser degree of perineal tearing, lower incidence of episiotomy application and extension, pain, decreased duration of labor, and decrease incidence of instrumental deliveries.
Clinical Bottom Line:
There seems to be no benefit to lithotomy positioning over other positioning in labor. In fact, Upright position may produce favorable maternal outcomes
But, non-lithotomy positions are not readily adopted in obstetrical settings. Labor positions should be decided in conjunction with the clinician, specifically obstetrician, to assess personal risk and benefit
More research, specifically in the United States, should be conducted with larger sample sizes.
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