Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Weill Cornell Medicine at New York Presbyterian Hospital, New York, NY.
Department of Obstetrics and Gynecology, New York Medical College, New York, NY.
Am J Obstet Gynecol MFM. 2021 Jul;3(4):100346. doi: 10.1016/j.ajogmf.2021.100346. Epub 2021 Mar 9.
Persistent occiput posterior and occiput transverse positions are associated with adverse maternal and neonatal outcomes. The objective of this study was to assess if the use of hands-and-knees posturing increased the rate of occiput anterior position immediately after posturing during the second stage of labor or at the time of birth.
An electronic search of PubMed, EMBASE, Clinicaltrials.gov, and Cochrane Central Register of Controlled Trials was performed from inception to September 2020.
Eligibility criteria included all randomized controlled trials of singleton gestations at ≥36 weeks' gestation that were randomized to either the hands-and-knees posture group or control group. The primary outcome was a composite of occiput anterior positioning during the second stage of labor or at birth. Individual components of the composite were assessed as secondary outcomes. Additional secondary outcomes were a change to occiput anterior position immediately after the intervention, use of regional anesthesia, duration of labor, mode of delivery, third- or fourth-degree perineal laceration, neonatal birthweight, and Apgar score less than 7 at 5 minutes.
The methodological quality of all the included studies was evaluated using the Cochrane Handbook for Systematic Reviews of Interventions. A meta-analysis was performed using the random effects model of DerSimmonian and Laird to produce a summary of the treatment effects in terms of relative risk or mean difference with 95% confidence intervals.
Of the 1079 studies screened, 5 met the inclusion criteria (n=1727 hands-and-knees posture vs n=1641 controls). When compared with the control group, patients who adopted the hands-and-knees posture had the same rate of occiput anterior positioning in the second stage of labor or at birth (81.2% vs 81.2%; relative risk, 1.03; 95% confidence interval, 0.92-1.14), as well as immediately after the intervention (34.1% vs 18.0%; relative risk, 1.60; 95% confidence interval, 0.88-2.90). On the basis of the post hoc subgroup analysis of patients with an ultrasound-diagnosed malposition before posturing, there was a higher rate of occiput anterior positioning immediately after the intervention (17.0% vs 10.3%; relative risk, 1.63; 95% confidence interval, 1.06-2.52), but this relationship did not persist at delivery. The remainder of the subgroup analyses and secondary outcomes were not significant.
Adopting a hands-and-knees posture does not increase the rate of occiput anterior positioning at time of delivery.
持续性枕后位和枕横位与母婴不良结局相关。本研究的目的是评估在第二产程中或分娩时采用手膝位是否会增加手膝位后即刻转为枕前位的比例。
从建库至 2020 年 9 月，对 PubMed、EMBASE、Clinicaltrials.gov 和 Cochrane 对照试验中心注册库进行了电子检索。
包括所有≥36 孕周的单胎妊娠的随机对照试验，随机分为手膝位组或对照组。主要结局是第二产程中或分娩时复合的枕前位。复合结局的各个组成部分被评估为次要结局。其他次要结局是干预后即刻转为枕前位、使用区域麻醉、产程持续时间、分娩方式、三度或四度会阴裂伤、新生儿出生体重和 5 分钟时 Apgar 评分＜7。
使用 Cochrane 干预系统评价手册评估所有纳入研究的方法学质量。使用 DerSimmonian 和 Laird 的随机效应模型进行荟萃分析，以产生治疗效果的总结，包括相对风险或均数差值及其 95%置信区间。
在筛选的 1079 项研究中，有 5 项符合纳入标准（n=1727 例手膝位与 n=1641 例对照组）。与对照组相比，采用手膝位的患者在第二产程或分娩时的枕前位比例相同（81.2% vs 81.2%；相对风险，1.03；95%置信区间，0.92-1.14），以及干预后即刻（34.1% vs 18.0%；相对风险，1.60；95%置信区间，0.88-2.90）。在手膝位前超声诊断胎位不正的患者亚组分析的基础上，干预后即刻枕前位的比例更高（17.0% vs 10.3%；相对风险，1.63；95%置信区间，1.06-2.52），但这种关系在分娩时并不持续。其余亚组分析和次要结局无显著差异。
采用手膝位并不会增加分娩时的枕前位比例。
