Randomised controlled trial of effect of hands and knees posturing on incidence of occiput posterior position at birth
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《英国医生杂志》
1 Midwifery Research, Hornsby Hospital, Palmerston Road, Hornsby, NSW 2077, Australia, 2 Department of Obstetrics and Gynaecology, Hornsby Hospital, 3 University of Sydney, Sydney, NSW 2006, Australia
Correspondence to: Azar Kariminia, Public Health Unit, Long Bay Complex, Anzac Parade, Malabar, PO Box 150, Matraville, NSW 2036, Australia karimia@chs.health.nsw.gov.au
Abstract
Occiput posterior position is the most common malposition of the fetus with a vertex presentation. It occurs in about 10-25% of pregnancies during the early stage of labour and in 10-15% during the active phase.1 2 Persistent fetal occiput posterior position at delivery has been reported in up to 6% of all deliveries.3 4 It is associated with deflexion of the fetal head and an increased incidence of prolonged painful labour, operative delivery, postpartum haemorrhage, vaginal trauma, maternal infection, and neonatal morbidity.5 6 A recent study has also shown a significant association between occiput posterior position during labour and newborn encephalopathy.7
Puddicombe first introduced the maternal hands and knees exercise as a way of facilitating fetal rotation antenatally in 1958.8 Subsequent authors have recommended the use of the hands and knees exercise as the optimal method of facilitating anterior fetal rotation.9-11 Studies in this area have been small, underpowered, and usually dependent on clinical palpation for the antenatal determination of fetal position. This has left them open to observer bias. A systematic review stressed that the hands and knees exercise cannot be recommended as an intervention until substantive evidence of its effect is available.12 The authors recommended that a randomised controlled trial should be conducted to guide clinical practice.
Despite limited evidence of a beneficial effect, the hands and knees exercise has been adopted in many maternity facilities in Australia. We sought to assess the efficacy of this intervention in decreasing the incidence of persistent fetal occiput posterior position at delivery.
Methods
Over three years we randomised 2547 women, of whom 1292 were assigned to the intervention group and 1255 to the control group. The figure shows the flow of participants through the various stages of the trial. Twenty nine (2%) women from the intervention group and 34 (3%) from the control group had a spontaneous onset of labour before 37 weeks of gestation or entered labour within 24 hours of randomisation. During the study period 217 (17%) women withdrew from the intervention group and 12 (1%) from the control group.
Flow of participants through the various stages of the trial. *Women were approached for recruitment if the clinic was not too busy
Table 1 shows the baseline characteristics of the two groups. The groups were comparable in terms of age, weight, body mass index, height, marital status, occupation, and parity. Most women (72% in both groups) were born in Australia; the distribution of other countries of birth was similar in the two groups. The baseline characteristics of the women who withdrew were comparable to those of all participants. Women withdrew from the study groups for a variety of reasons (table 2). We included all randomised women in the analysis.
Table 1 Baseline characteristics of women randomised (n=2547). Values are numbers (percentages) unless stated otherwise
Table 2 Reasons for withdrawal from study. Values are numbers (percentages)
Primary outcome
A persistent fetal occiput posterior position was recorded in 105 (8.1%) women in the intervention group and 98 (7.8%) in the control group (table 3). This difference was not statistically significant (difference in risk 0.3%, 95% confidence interval -1.8% to 2.4%). The incidence of transverse arrest was also similar: 44 (3.4%) in the intervention group and 38 (3.0%) in the control group. Even after exclusion of women who withdrew from the study or had early labour, the incidence of persistent occiput posterior position was 7.8% (82/1046) in the intervention group and 7.9% (96/1209) in the control group. The incidence of transverse arrest was then 3.3% (35/1046) for the intervention group and 3.1% (38/1209) for the control group.
Table 3 Primary and secondary outcomes (intention to treat analysis). Values are numbers (percentages) unless stated otherwise
We also examined the effect of hands and knees exercise on the position of the fetus with adjustment for parity, as parity has been reported as a risk factor for occiput posterior position.6 In a univariate analysis, we found that nulliparity was associated with an increased risk of occiput posterior position at birth (odds ratio 2.5, 95% confidence interval 1.9 to 3.3). Even after adjustment for parity, hands and knees exercise showed no effect on the position of the baby (odds ratio 0.94, 0.73 to 1.21). We found no significant interaction between parity and exercise.
Secondary outcomes
We found no differences between the intervention and control groups in induction of labour, use of epidural, duration of labour, mode of delivery, use of episiotomy, or Apgar score (table 3).
Adherence
Of 1046 women in the intervention group who remained in the study until the onset of labour, 371 (36%) did the exercise between 15 and 28 times, 364 (35%) did it 29-42 times, and 122 (12%) did it 43 times or more. Most of the women who did the exercise least often did so because they delivered between 37 and 40 weeks rather than because of non-compliance with the protocol.
Of the 217 women who withdrew from the study, most (139, 64%) did the exercise between 1 and 14 times before withdrawal. Twelve (6%) women did the exercise 15-28 times, and only 2 (1%) women did the exercise between 29 and 42 times. In addition to these 217 women, 29 women had a spontaneous onset of labour before 37 weeks or within 24 hours of randomisation without starting hands and knees exercise.
When we examined the exercise log of the women in the control group who remained in the study, a small proportion (8; 0.7%) had also done hands and knees exercises more than 15 times. A further 18 (2%) women had done the exercise 1-14 times before going into labour.
We reanalysed the data taking into account the number of times the women did the hands and knees exercise. Again, we found no effect of the level of exercise on the incidence of occiput posterior position at birth.
Discussion
Neri A, Kaplan B, Rabinerson D, Sulkes J, Ovadia J. The management of persistent occiput-posterior position. Clin Exp Obstet Gynecol 1995;22: 126-31.
Cunningham FG, MacDonald PC, Gant NF, Leveno KJ, Gilstrap LC, Hankins GD. Williams obstetrics. 20th ed. Stamford, CT: Appleton and Lange, 1997.
Gardberg M, Tuppurainen M. Intrapartum sonography and persistent occiput posterior position: a study of 408 deliveries. Obstet Gynecol 1998;91: 746-9.
Royal North Shore Hospital 1996 labour ward statistics, ninth annual report. Sydney: Royal North Shore Hospital, 1997.
Pearl ML, Roberts JM, Laros RK, Hurd WW. Vaginal delivery from the persistent occiput posterior position: influence on maternal and neonatal morbidity. J Reprod Med 1993;38: 955-61.
Fitzpatrick M, McQuillan K, O'Herlihy C. Influence of persistent occiput posterior position on delivery outcome. Obstet Gynecol 2001;98: 1027-31.
Badawi N, Kurinczuk JJ, Keogh JM, Alessandri LM, O'Sullivan F, Burton PR, et al. Intrapartum risk factors for newborn encephalopathy: the Western Australian case-control study. BMJ 1998;317: 1554-8.
Puddicombe JF. Maternal posture for correction of posterior fetal position. International College of Surgeons 1958;23: 73-7.
Andrews CM. Nursing intervention to change a malpositioned fetus. J Adv Nurs 1981;3: 53-6.
Andrews CM, Andrews EC. Nursing, maternal postures, and fetal position. Nurs Res 1983;32: 336-41.
Biancuzzo M. The patient observer: does the hands-and-knees posture during labour help to rotate the occiput posterior fetus? Birth 1991;18: 40-7.
Hofmeyr GJ, Kulier R. Hands/knees posture in late pregnancy or labour for fetal malposition (lateral or posterior). Cochrane Database Syst Rev 2002;(4): CD0010163.
Public Health Division. New South Wales mothers and babies 2000. Sydney: New South Wales Department of Health, 2001.
Riethmuller D, Teffaud O, Eyraud JL, Sautiere JL, Schaal JP, Maillet R. Maternal and fetal prognosis of occiput posterior presentation. J Gynecol Obstet Biol Reprod 1999;28: 41-7.(Azar Kariminia, research )
Correspondence to: Azar Kariminia, Public Health Unit, Long Bay Complex, Anzac Parade, Malabar, PO Box 150, Matraville, NSW 2036, Australia karimia@chs.health.nsw.gov.au
Abstract
Occiput posterior position is the most common malposition of the fetus with a vertex presentation. It occurs in about 10-25% of pregnancies during the early stage of labour and in 10-15% during the active phase.1 2 Persistent fetal occiput posterior position at delivery has been reported in up to 6% of all deliveries.3 4 It is associated with deflexion of the fetal head and an increased incidence of prolonged painful labour, operative delivery, postpartum haemorrhage, vaginal trauma, maternal infection, and neonatal morbidity.5 6 A recent study has also shown a significant association between occiput posterior position during labour and newborn encephalopathy.7
Puddicombe first introduced the maternal hands and knees exercise as a way of facilitating fetal rotation antenatally in 1958.8 Subsequent authors have recommended the use of the hands and knees exercise as the optimal method of facilitating anterior fetal rotation.9-11 Studies in this area have been small, underpowered, and usually dependent on clinical palpation for the antenatal determination of fetal position. This has left them open to observer bias. A systematic review stressed that the hands and knees exercise cannot be recommended as an intervention until substantive evidence of its effect is available.12 The authors recommended that a randomised controlled trial should be conducted to guide clinical practice.
Despite limited evidence of a beneficial effect, the hands and knees exercise has been adopted in many maternity facilities in Australia. We sought to assess the efficacy of this intervention in decreasing the incidence of persistent fetal occiput posterior position at delivery.
Methods
Over three years we randomised 2547 women, of whom 1292 were assigned to the intervention group and 1255 to the control group. The figure shows the flow of participants through the various stages of the trial. Twenty nine (2%) women from the intervention group and 34 (3%) from the control group had a spontaneous onset of labour before 37 weeks of gestation or entered labour within 24 hours of randomisation. During the study period 217 (17%) women withdrew from the intervention group and 12 (1%) from the control group.
Flow of participants through the various stages of the trial. *Women were approached for recruitment if the clinic was not too busy
Table 1 shows the baseline characteristics of the two groups. The groups were comparable in terms of age, weight, body mass index, height, marital status, occupation, and parity. Most women (72% in both groups) were born in Australia; the distribution of other countries of birth was similar in the two groups. The baseline characteristics of the women who withdrew were comparable to those of all participants. Women withdrew from the study groups for a variety of reasons (table 2). We included all randomised women in the analysis.
Table 1 Baseline characteristics of women randomised (n=2547). Values are numbers (percentages) unless stated otherwise
Table 2 Reasons for withdrawal from study. Values are numbers (percentages)
Primary outcome
A persistent fetal occiput posterior position was recorded in 105 (8.1%) women in the intervention group and 98 (7.8%) in the control group (table 3). This difference was not statistically significant (difference in risk 0.3%, 95% confidence interval -1.8% to 2.4%). The incidence of transverse arrest was also similar: 44 (3.4%) in the intervention group and 38 (3.0%) in the control group. Even after exclusion of women who withdrew from the study or had early labour, the incidence of persistent occiput posterior position was 7.8% (82/1046) in the intervention group and 7.9% (96/1209) in the control group. The incidence of transverse arrest was then 3.3% (35/1046) for the intervention group and 3.1% (38/1209) for the control group.
Table 3 Primary and secondary outcomes (intention to treat analysis). Values are numbers (percentages) unless stated otherwise
We also examined the effect of hands and knees exercise on the position of the fetus with adjustment for parity, as parity has been reported as a risk factor for occiput posterior position.6 In a univariate analysis, we found that nulliparity was associated with an increased risk of occiput posterior position at birth (odds ratio 2.5, 95% confidence interval 1.9 to 3.3). Even after adjustment for parity, hands and knees exercise showed no effect on the position of the baby (odds ratio 0.94, 0.73 to 1.21). We found no significant interaction between parity and exercise.
Secondary outcomes
We found no differences between the intervention and control groups in induction of labour, use of epidural, duration of labour, mode of delivery, use of episiotomy, or Apgar score (table 3).
Adherence
Of 1046 women in the intervention group who remained in the study until the onset of labour, 371 (36%) did the exercise between 15 and 28 times, 364 (35%) did it 29-42 times, and 122 (12%) did it 43 times or more. Most of the women who did the exercise least often did so because they delivered between 37 and 40 weeks rather than because of non-compliance with the protocol.
Of the 217 women who withdrew from the study, most (139, 64%) did the exercise between 1 and 14 times before withdrawal. Twelve (6%) women did the exercise 15-28 times, and only 2 (1%) women did the exercise between 29 and 42 times. In addition to these 217 women, 29 women had a spontaneous onset of labour before 37 weeks or within 24 hours of randomisation without starting hands and knees exercise.
When we examined the exercise log of the women in the control group who remained in the study, a small proportion (8; 0.7%) had also done hands and knees exercises more than 15 times. A further 18 (2%) women had done the exercise 1-14 times before going into labour.
We reanalysed the data taking into account the number of times the women did the hands and knees exercise. Again, we found no effect of the level of exercise on the incidence of occiput posterior position at birth.
Discussion
Neri A, Kaplan B, Rabinerson D, Sulkes J, Ovadia J. The management of persistent occiput-posterior position. Clin Exp Obstet Gynecol 1995;22: 126-31.
Cunningham FG, MacDonald PC, Gant NF, Leveno KJ, Gilstrap LC, Hankins GD. Williams obstetrics. 20th ed. Stamford, CT: Appleton and Lange, 1997.
Gardberg M, Tuppurainen M. Intrapartum sonography and persistent occiput posterior position: a study of 408 deliveries. Obstet Gynecol 1998;91: 746-9.
Royal North Shore Hospital 1996 labour ward statistics, ninth annual report. Sydney: Royal North Shore Hospital, 1997.
Pearl ML, Roberts JM, Laros RK, Hurd WW. Vaginal delivery from the persistent occiput posterior position: influence on maternal and neonatal morbidity. J Reprod Med 1993;38: 955-61.
Fitzpatrick M, McQuillan K, O'Herlihy C. Influence of persistent occiput posterior position on delivery outcome. Obstet Gynecol 2001;98: 1027-31.
Badawi N, Kurinczuk JJ, Keogh JM, Alessandri LM, O'Sullivan F, Burton PR, et al. Intrapartum risk factors for newborn encephalopathy: the Western Australian case-control study. BMJ 1998;317: 1554-8.
Puddicombe JF. Maternal posture for correction of posterior fetal position. International College of Surgeons 1958;23: 73-7.
Andrews CM. Nursing intervention to change a malpositioned fetus. J Adv Nurs 1981;3: 53-6.
Andrews CM, Andrews EC. Nursing, maternal postures, and fetal position. Nurs Res 1983;32: 336-41.
Biancuzzo M. The patient observer: does the hands-and-knees posture during labour help to rotate the occiput posterior fetus? Birth 1991;18: 40-7.
Hofmeyr GJ, Kulier R. Hands/knees posture in late pregnancy or labour for fetal malposition (lateral or posterior). Cochrane Database Syst Rev 2002;(4): CD0010163.
Public Health Division. New South Wales mothers and babies 2000. Sydney: New South Wales Department of Health, 2001.
Riethmuller D, Teffaud O, Eyraud JL, Sautiere JL, Schaal JP, Maillet R. Maternal and fetal prognosis of occiput posterior presentation. J Gynecol Obstet Biol Reprod 1999;28: 41-7.(Azar Kariminia, research )