Accepted Manuscript Comparison of maternal and neonatal outcomes between hands-and-knees and supine delivery positions Hong-Yu Zhang, Yong Shu, Ning-Ning Zhao, Yu-Jing Lu, Min Chen, Ying-Xia Li, JunQin Wu, Li-Hua Huang, Xiao-Lan Guo, Yu-Hong Yang, Xiao-Li Zhang, Xiao-Yu Zhou, Ren-Fei Guo, Jing Li, Wen-Zhi Cai PII:
S2352-0132(15)30054-5
DOI:
10.1016/j.ijnss.2016.05.001
Reference:
IJNSS 183
To appear in:
International Journal of Nursing Sciences
Received Date: 10 November 2015 Revised Date:
24 January 2016
Accepted Date: 2 May 2016
Please cite this article as: H.-Y. Zhang, Y. Shu, N.-N. Zhao, Y.-J. Lu, M. Chen, Y.-X. Li, J.-Q. Wu, L.H. Huang, X.-L. Guo, Y.-H. Yang, X.-L. Zhang, X.-Y. Zhou, R.-F. Guo, J. Li, W.-Z. Cai, Comparison of maternal and neonatal outcomes between hands-and-knees and supine delivery positions, International Journal of Nursing Sciences (2016), doi: 10.1016/j.ijnss.2016.05.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Comparing
maternal
and
neonatal
outcomes
between
hands-and-knees delivery position and supine position Short title: Hands-and-knees position delivery reduce episiotomy
RI PT
Hong-Yu Zhang a, Yong Shu b, Ning-Ning Zhao c, Yu-Jing Luc, Min Chen d, Ying-Xia Li e, Jun-Qin Wu f, Li-Hua Huang g, Xiao-Lan Guo h, Yu-Hong Yang i, Xiao-Li Zhang j, Xiao-Yu Zhou k
, Ren-Fei Guo l, Jing Lim, Wen-Zhi Cai b
b Nanfang Medical university, Guangzhou 520000,China
SC
a Nursing Dept. of Hainan Medical University, Haikou 571119, China
c Dept. of Obstetric, Cangxian Hospital, Cangzhou 061000, China
M AN U
d Dept. of Obstetric, Dongchang Maternal and Child Health Hospital, Liaocheng 252000, China e Dept. of Obstetric, Gongan People’s Hospital, Jingzhou 434300, China f Dept. of Obstetric, Yanshan People’s Hospital, Cangzhou 061300, China g Dept. of Obstetric, Dongguan Maternal and Child Health Hospital, Dongguan 523002, China h Dept. of Obstetric, Baoan Maternal and Child Health Hospital, Shenzhen 518101, China
TE D
i Dept. of Obstetric, Juxian People’s Hospital, Rizhao 276500, China j Dept. of Obstetric, East Part of the Fourth Hospital of Hebei Medical University, Shijiazhuang 050035, China
EP
k Dept. of Obstetric, Nanhai People’s Hospital, Foshan 528200, China l Dept. of Obstetric, Haikou Maternal and Child Health Hospital, Haikou 571100, China
AC C
m Dept. of Obstetric, Jiangmen Wuhu Chinese medicine hospital, Jiangmen 529020, China
Correspondence to: Hong-Yu Zhang
Department of midwifery, Hainan Medical University, Xueyuan road No. 3, Haikou 571119, China. Email:
[email protected]
(H.-Y. Zhang)
1
ACCEPTED MANUSCRIPT
Authors’ Contributions H.-Y. Zhang conceived the study and performed statistical analyses. N.-N .Zhao , Y.-J. Lu, M. Chen , Y.-X. Li , J.-Q. Wu , L.-H. Huang, X.-L. Guo, Y.-H.Yang,
RI PT
X.-L.Zhang, X.-Y. Zhou, R.-F. Guo, J.- L. etc. collected the data , R. Shu and W-Z Cai
participated in the design, collected the data, and drafted the manuscript. All authors read and approved the final manuscript.
SC
Acknowledgement
We sincerely thank to all hospitals collagens participate in the collection of the data,
M AN U
thanks to all women who were willing to be delivered hands and knees position because that was no routine procedures in China so far.
Thanks to prof. CAI Wen-zhi professional support on the process of editing and rewriting the paper.
TE D
Conflict of interest and financial disclosure statement
AC C
EP
We declare that there is no conflict of Interest for all authors appear in this paper
2
ACCEPTED MANUSCRIPT Comparison of maternal and neonatal outcomes between hands-and-knees and supine delivery positions Short title: Hands-and-knees delivery position reduces the need for episiotomy
TE D
M AN U
SC
RI PT
Background: The supine position is the most common birth position adopted in China, but the World Health Organization recommends non-supine positions for delivery. The hands-and-knees position shows several advantages, such as wide pelvic diameter and easy fetal rotation during delivery. Small trials conducted in China in 2011 revealed that the hands-and-knees position resulted in improved maternal and neonate outcomes than those in the supine position. However, a comprehensive study must be conducted before the hands-and-knees position can be introduced into clinical practice. Hence, we conducted this multicenter trial to comprehensively examine the benefits of the hands-and-knees position over the supine position during delivery. Methods: Our clinical study was conducted in 11 hospitals in China from May to December 2012. A total of 446 pregnant women who gave birth in the hands-and-knees position were assigned into the experimental group, and 440 women who gave birth in the supine position were classified into the control group. Episiotomy rate was evaluated as the primary outcome, and perineum laceration degree was considered the secondary outcome. Results: Women in the experimental group achieved lower rates of episiotomy and higher rates of intact perineum and first-degree perineum lacerations compared with those in the control. Postpartum bleeding amount, neonatal asphyxia, and APGAR scores at 1 and 5 min were not significantly different between the two groups. Conclusions: This study proves that women who delivered in the hands-and-knees position achieved low rates of episiotomy and intact perineum. Moreover, the rates of neonatal asphyxia and postpartum bleeding did not increase. Pregnant patients who prefer to adopt the hands-and-knees position should be assisted in assuming such position during delivery.
Keywords: supine delivery position; hands-and-knees delivery position; episiotomy
EP
1. Introduction
The up-right position is a simple and low-cost intervention that increases the
AC C
likelihood of normal vaginal birth [1]. Upright positions (including standing, sitting, and hands-and-knees) during childbirth can benefit women by allowing spontaneous pushing, efficient contractions, short second stage of labor, less intervention, and high patient tolerance to labor pain [2–4]. Limited information is available regarding the advantages and disadvantages of different “non-supine positions.” No significantly different reported between kneeling and upright sitting delivery positions [5] or between using a birthing seat and any 1
ACCEPTED MANUSCRIPT other delivery position [6]. The hands-and-knees position involves laboring woman “on all fours,” which means being prostrate with four limbs on the floor or bed, similar to a crawling baby [7]. In this position, the abdomen is suspended and the hips
RI PT
are at a right angle to the floor or bed [7]. The hands-and-knees position results in a wide pelvic diameter, which facilitates the descent and rotation of the fetal head and decrease the incidence of shoulder dystocia [7]. The hands-and-knees position can
SC
also convert the occipitoposterior presentation to occipitoanterior during labor [8].
M AN U
In a previous study [9], pelvimetry was performed in 35 non-pregnant female volunteers who assumed supine, hands-and-knees, and squatting positions. The results revealed that the sagittal outlet in the hands-and-knees (11.8 ± 1.3 cm) and squatting (11.7 ± 1.3 cm) positions exceeded that in the supine position (11.5 ± 1.3 cm; p =
TE D
0.002 and P = 0.01, respectively). Similar observations were noted in interspinous diameters (11.6 ± 1.1 and 11.7 ± 1.0 cm vs. 11.0 ± 0.7 cm; P < 0.0001, in both cases). Thus, both hands-and-knees and squatting positions can facilitate delivery [9, 10]. In
EP
the supine position, the pelvis is tilted anteriorly in the supine position; the presenting
AC C
part is forced to travel posteriorly to the curve of the sacrum and then moves again upward in an S-shaped curve, thereby complicating fetal descent. When a pregnant woman is in the hands-and-knees position, the spine and pelvis assume a C-shaped curve, which facilitates fetal passage [11]. Hence, this position was recommended by Inner May Gaskin as an efficient method to resolve shoulder dystocia (Gaskin maneuver) [12]. Based on the literature, the hands-and-knees position provides the optimal benefits, including wide pelvic diameter and easy fetal passage [11].
2
ACCEPTED MANUSCRIPT Although the hands-and-knees position exhibits theoretical advantages, the clinical application of this technique is severely hampered by the lack of compelling evidence to support its effectiveness. This position was investigated in a study with
RI PT
small sample size in China [13]; in this study, 113 women were randomized into two groups, namely, women who gave birth in the hands-and-knees position (experimental group, n = 51) and those who delivered in the supine position (control group, n = 62).
SC
The experimental group showed shorter second stage of labor and lower rates of
M AN U
episiotomy without increasing the rate of neonatal asphyxia. However, introducing this position to clinical application is limited by the lack of solid scientific evidence [14]. Hence, the hands-and-knees position must be further investigated using multi-center clinical studies. The present study aims to compare maternal and
TE D
neonatal outcomes between low-risk women randomized to birth with the
episiotomy. 2. Methods Design
AC C
2.1.
EP
hands-and-knees and supine positions and examine factors affecting the rate of
This study is a prospective, two-group randomized, controlled trial.
2.2.
Setting and participants The study participants included women who gave birth at 11 hospitals in
China selected by convenience; these hospitals included five maternal and child health hospitals and seven general hospitals. Data were collected between May and December 2012. During this period, the average annual birth number in the 11
3
ACCEPTED MANUSCRIPT participating hospitals was 14,000. The inclusion criteria included a) having a healthy, uncomplicated pregnancy without any medical diagnosis; b) anticipating vaginal delivery of a singleton fetus in cephalic presentation and longitudinal lie and
RI PT
spontaneous onset of labor at gestational weeks between (37 + 0) and (41 + 6); and c) The body-mass index (BMI) of less than 30. Moreover, the participants must understand Mandarin to comprehend the instructions. The exclusion criteria included
SC
women with pregnancy complications, premature rupture of membranes, medical
M AN U
contraindications, physical limitations that do not allow the hands-and-knees position, and/or with fetus in the non-cephalic presentation or breech position and/or of less than 37 or over 42 weeks of gestation.
An assisting midwife verified the eligibility of the patient for participation in
TE D
the trial on the basis of the inclusion criteria upon admission to the delivery ward. 2.3. Sample size calculation
According to a pilot study, episiotomy rate differed by 25% between the
EP
groups (the episiotomy rates in the experimental and control groups were 15% and
AC C
40%, respectively); as such, 48 participants per group and a total of 92 participants were required to achieve a power of 80% at a significance level of 0.05 (two-sided) [15]. However, the present study recruited as many participants as possible during data collection. 2.4.
Randomization Equal numbers of 150 opaque and sealed envelopes containing
randomization assignments were randomly mixed, numbered, and placed in the office
4
ACCEPTED MANUSCRIPT of the labor wards of each participating hospital. Each envelope also contained a data collection sheet. When a woman was admitted in active labor, the midwife asked whether the patient is willing to participate and if so, drew an envelope in strict
2.5.
RI PT
numerical succession. Intervention
SC
The principal investigator ZHY and trial coordinator HSR conducted presentations to the obstetrical nursing staff to ensure that the involved medical team
M AN U
in every hospital understood the research protocol. The hospital research nurse conducted training sessions with the nursing staff to ensure that all nurses were comfortable in assisting women to assume the hands-and-knees position and cognizant of the trial enrolment procedure. Women in the experimental group were
TE D
assisted to take a free position during the first stage of labor and directed to maintain the hands-and-knees position for delivery during the second stage. The heads of the
EP
delivery beds were increased to 30°–60° from the horizontal. Each subject was assisted to assume the prone position while kneeling on cushions with the support of
AC C
her palms or fists (for women with carpal tunnel syndrome). The subject held this pose for 15–30 min and then rested in the semi-recumbent or lateral position for 5–10 min. The process was repeated until the end of the second stage of labor and finally delivered the babies in the hands-and-knees position. The subjects who found the position uncomfortable were allowed to assume another more comfortable position but were encouraged to attempt the hands-and-knees position again at a later time. The hands-and-knees position was discontinued for patients who showed negative 5
ACCEPTED MANUSCRIPT effects on fetal heart rate pattern or maternal blood pressure. In this case, the patient was adjusted to the supine position while waiting for placental delivery (Figure 1). Women in the control group were also allowed to take free positions during the first
RI PT
stage of labor and early second stage. These women assumed the supine position for delivery. All research nurses were trained to assist women to receive the allocated delivery position.
SC
Figure 1 here
M AN U
During the second stage of labor, both groups received the hands-off method to protect the perineum (achieved by controlling the delivery of the head without holding against the perineum while pushing by hand). The women were allowed to strain spontaneously with modified breathing during the contraction period [16–18].
TE D
Delayed cord clamping (clamping the cord at pulsation cessation or placental delivery) was adopted in both groups [19–21]. 2.6.
Measurements and data collection
EP
The primary outcome was episiotomy rate, and the secondary outcomes
AC C
included degree of perineum laceration (judged by the new classification called “four degrees of the perineum tear”) [22], rate of natural delivery, rate of shoulder dystocia, postpartum bleeding, neonatal APGAR score, and rate of neonatal asphyxia. All these outcome measurements were available from electronic case notes. In the envelope randomly assigned to each participant, a random number and a data collection sheet were enclosed to obtain demographic data and other aforementioned information. The patients who did not follow the birth position as
6
ACCEPTED MANUSCRIPT instructed were directed by the midwives to specify their reason in the data collection sheet. Figure 2 shows the flowchart of the consolidated standards of reporting trials
RI PT
(CONSORT) employed in this study. Among the 5,808 women who were assessed for eligibility, 1021 were deemed ineligible. The main reasons for exclusion included high-risk pregnancy, epidural anesthesia for pain relief, and spontaneous rupture of
SC
membranes without spontaneous contractions for longer than 24 h. Among the 4,787
M AN U
women who were eligible to participate in this study, 1400 provided a written consent and were recruited. In total, 886 patients completed the protocol; 446 cases belonged to the experimental group, and 440 cases were assigned to the control group. A total of 480 women withdrew from the study because of lack of willingness to follow the
TE D
allocated intervention. The participants were mainly young, with a mean age of 23.93 ± 3.78 years, and the majority of them were primiparous (67.5% and 66.1% in the
EP
experimental and control groups, respectively).
AC C
Figure 2 here
2.7.
Ethical considerations Ethical approval was obtained from the health research ethics boards of all
the participating hospitals. The midwives employed in the involved institutions (ZNN, LYJ, CM, LYX, WJQ, HLH, GXL, MFL, YYH, ZXL, ZXY, GRF, WAB, and LJ) provided written and oral information to the participants and explained the purpose
7
ACCEPTED MANUSCRIPT and nature of the research The midwives also guaranteed the confidentiality of the data collected and anonymity of the participants and relayed the maternal right to refuse participation as potential participants. Women who were willing to participate
RI PT
in the study provided written consents and were subsequently recruited. All of the participants gave written consent to participate in the study. The subjects were permitted to withdraw from the study at any time during the trial by informing the
Data analysis
M AN U
2.8.
SC
nurse staff.
Data analyses were performed using IBM SPSS Statistics for Windows version 21 (IBM Corp., Armonk, NY). Descriptive statistics were used to report the demographics of the participants and the levels of outcome variables. Independent
TE D
sample t-test was applied to compare continuous data of pregnant weeks, maternal age, neonatal birth weight, time of second stage and third stages of labor, and postpartum bleeding between the groups. For categorical data, chi-square test was used to
EP
determine differences in variables between the groups. Logistic regression was
AC C
adopted to examine factors affecting episiotomy rate. The level of statistical significance was set at P < 0.05, and all inferential tests were two-tailed. 3.
3.1.
Findings
Demographic and clinical characteristics of participants The distribution of 886 women among 11 hospitals is presented in Table 1.
Four hospitals presented insufficient cases because both midwives and women in delivery doubted the safety of the hands-and-knees position. Moreover, six hospitals
8
ACCEPTED MANUSCRIPT recruited more than 50 cases per group. The demographic and clinical characteristics of the participants are shown in Table 2. Age, pregnant weeks, neonatal weight, ratio of primipara, and the rate of fetal macrosomia were not significantly different
RI PT
between the two groups.
Table 1 and 2 here
Comparison of intact perineum, perineum laceration, and episiotomy rates
SC
3.2.
between the two groups
M AN U
Compared with women who lay supine during delivery, those who assumed the hands-and-knees position attained higher rates of intact perineum (14.8% and 33.2%, respectively) (χ2 = 41.11, p < 0.001), higher rates of first degree laceration (41.8% and 56.3%, respectively) (χ2 = 18.53, p < 0.001), and lower rates of
TE D
episiotomy (37.7% and 1.8%, respectively) (χ2 = 181.21, p < 0.001). The rate of second-degree laceration between the groups was not statistically significantly
EP
different. However, episiotomy was regarded as second-degree laceration (29). As such, the rate of second-degree lacerations, including episiotomy rate, is lower in the group
AC C
experimental
than
that
in
the
control
group
(10.5% and 43.4%, respectively) (χ2 = 121.8, p < 0.001) (Table 3). Thus, the first hypothesis was supported. Postpartum bleeding amount was not significantly different between the two groups (t = 0.63, p = 0.52). Severe postpartum bleeding over 1000 ml were not observed in both groups. The differences in the rate of newborn asphyxia were not significant between the two groups. Participants in the experimental group underwent 9
ACCEPTED MANUSCRIPT spontaneous vaginal births, whereas four cases of shoulder dystocia were recorded in the control group (χ2 = 4.07, p = 0.04). Table 3 here
RI PT
Logistic regression analysis revealed that the hands-and-knees position was a protective factor for episiotomy. The age of gestation in weeks also increased the rate of episiotomy. Women who experienced severe postpartum bleeding tended to present
SC
increased rate of episiotomy (p = 0.03) (Table 4). Hence, the second hypothesis was
4.
M AN U
supported.
Discussion
Table 4 here
TE D
The supine position is the predominant labor position in mainland China. This general practice deviates from the World Health Organization guidelines for normal birth, which recommends non-supine positions as the efficient intervention to
EP
achieve favorable maternal and neonatal outcomes [23]. The hands-and-knees
AC C
delivery position is not usually employed. Shifting from a supine to a non-supine position is a great challenge to both women in labor and health workers in practice. 4.1.
Birth position and perineum laceration This study showed that mothers in the experimental group presented
significantly higher rates of intact perineum and first-degree laceration as well as significantly lower rates of episiotomy compared with those in the control group. The rate of second-degree laceration did not differ significantly between the two groups.
10
ACCEPTED MANUSCRIPT Logistic regression analysis also revealed that the hands-and-knees position was a protective factor for episiotomy. This study showed that episiotomy rate decreased in the experimental group by a power of 0.024 (95.0% confidence interval for Odds ratio
RI PT
(0.011---0.051). Clinical observations showed that women who give birth in the supine position were more likely to suffer severe perineum swelling during pushing process,
SC
which could be mitigated when the women shift to the hands-and-knees position.
M AN U
Hence, the hands-and-knees position could improve blood circulation and relieve perineal swelling. The enhanced blood circulation could also protect the fetus. The effect of the hands-and-knees position on preventing perineum trauma must be investigated in future studies.
Hands-and-knees position and shoulder dystocia
TE D
4.2.
Shoulder dystocia was noted in four cases in the control group but was not observed in the experimental group; this finding reveals the potential benefit of the
EP
hands-and-knees position in the prevention of shoulder dystocia. A previous study [24]
AC C
concluded that the hands-and-knees position generates a wide pelvic diameter, which could facilitate fetal delivery by adducting the shoulder of the fetus through uterine contraction, impact force of the fetal head, and gravity. Another previous work reported that 83% of the shoulder was relocated from the sacral bone by a single Gaskin (hands-and-knees position) [12]. The present study supports the application of the hands-and-knees position as routine delivery position for pregnant women to potentially reduce the incidence of dystocia, particularly shoulder dystocia.
11
ACCEPTED MANUSCRIPT 4.3.
Neonatal outcomes and the hands-and-knees position One disadvantage of the supine position is the potential supine hypotension,
which could cause poor blood supply to the uterus and lead to fetal distress. A study
RI PT
concluded that the upright position resulted in fewer cases of abnormal fetal heart rate [25]. In the present study, rate of neonatal asphyxia and APGAR scores were not significantly different between the two groups. This hypothesis must be verified in
SC
future studies with large sample sizes because of the low incidence of neonatal
M AN U
asphyxia in low-risk women. 4.4. Strengths and limitations of this study
This study presents a number of strengths. The study utilized a multicenter, randomized, controlled trial design and employed a large sample size. Multiple
TE D
outcome variables were also adopted to measure maternal and fetal outcomes. This work is also relevant to obstetric practices in mainland China because the hands-and-knees position is not commonly applied in delivery settings.
EP
However, this study exhibits some limitations. The large number of women
AC C
who withdrew from the study potentially affected the power of the investigation. The main reasons behind the withdrawals from the experimental group included knee pain and discomfort while maintaining the hands-and-knees position during labor. Some midwives also complained of the need for additional helpers when adopting such position. This problem may be due to fact that women were forced to deliver on a labor bed, which was designed to be excessively high and narrow; the women were not allowed to deliver on land where they could move freely. Meanwhile, the main
12
ACCEPTED MANUSCRIPT reason for withdrawal in the control group was the unwillingness to answer follow up interview questions. The hospitals included in the study could not apply the double-blinded
RI PT
method because of the nature of the observation entailed. This limitation may have affected some outcomes, such as rate of episiotomy and duration of the second labor stage. Moreover, the perceptions of the participants with regard to assuming the
SC
hands-and-knees position were not explored, thereby limiting the qualitative evidence
M AN U
that may be used to convince other mothers to consider such position. 4.5. Recommendations for future studies
Further research on the hands-and-knees position must be performed to improve maternal and neonatal outcomes. Investigations must focus on comparison
TE D
between the hands-and-knees position and other upright positions in terms of maternal and neonatal outcomes, implementation of the hands-and-knees delivery position in different locations (bed, land, or water birth), and effect of the hands-and-knees
EP
position on women with cephalopelvic disproportion and breech birth. In addition,
AC C
future studies must also explore the perceptions of mothers who assume the hands-and-knees position for encouraging midwives to provide additional care to the mothers during labor.
Conclusions and implications for practice This study provides clinical evidence of significantly lower rates of episiotomy, higher rates of intact premium, lower rates of shoulder dystocia, and unaffected rates of neonatal asphyxia and postpartum bleeding amount in women who
13
ACCEPTED MANUSCRIPT delivered in hands-and-knees position compared with those who gave birth in the supine position. Understanding of the effectiveness of the hands-and-knees position could help promote the use of this position in clinical practice.
RI PT
Healthcare professionals, such as nurses and midwives, must be trained to support pregnant patients in assuming the hands-and-knees position and encouraged to incorporate the position in their daily clinical practice.
SC
References
AC C
EP
TE D
M AN U
[1] Bodner-Adler B, Bodner K, Kimberger O, Lozanov P, Husslein P, Mayerhofer K. Women’s position during labour: influence on maternal and neonatal outcome. Wien Klin Wochenschr 2003;31;115(19-20):720-3. [2] De Jong PR, Johanson RB, Baxen P, Adrians VD, van der Westhuisen S, Jones PW. Randomised trial comparing the upright and supine positions for the second stage. Br J Obstet Gynaecol 1997;104(5):567-71. [3] De Jonge A1, Teunissen DA, van Diem MT, Scheepers PL, Lagro-Janssen AL.Women’s position during second stage of labour: views of primary care midwives. J Adv Nurs 2008 ;63(4):347-56. [4]Gupta JK, Nikodem VC, Woman’s position during second stage of labor. Cochrane Database Syst Rev2000. 2:CD002006. [5] Thies-Lagergren L, Kvist LJ, Christensson K, Hildingsson I: No reduction in instrumental vaginal births and no increased risk for adverse perineal outcome in nulliparous women giving birth on a birth seat: results of a Swedish randomized controlled trial. BMC Pregnancy Childbirth 2011, 11:22. [6] Altman D, Ragnar I, Ekstrom A, Tyden T, Olsson SE: Anal sphincter lacerations and upright delivery postures-a risk analysis from a randomized controlled trial. Int Urogynecol J Pelvic Floor Dysfunct 2007, 18:141–146. [7] Bruner JP, Drummond SB, Meenan AL, Gaskin IM.All-fours maneuver for reducing shoulder dystocia during labor. J Reprod Med1998;43(5):439-43. [8]Stremler R, Hodnett E, Petryshen P, Stevens B, Weston J, Willan A. Randomized trial of hands-and-knees position for occipitoposterior position in labor. Birth 2005;32(4):243–251. [9] Michel SC, Rake A, Treiber K et al. MR Obstetric Pelvimetry: Effect of Birthing Position on Pelvic Bony Dimensions. AJR Am J Roentgenol 2002 ;179(4):1063-7. [10] Russell JG. Molding of the pelvic outlet. J Obstet Gynaec Brit Cwlth 1969;76: 817–820. [11] Mendez-Bauer.Effects of standing position on spontaneous uterine contractility and other aspects of labor. J Perinat Med 1975;3 (2):89-100. 14
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
[12]Gaskin IM.How being a homebirth midwife enabled me to learn about shoulder dystocia.Midwifery Today Int Midwife 2012;(103):12-3. [13] Guo X, Zhang H, Hands and knees position delivery on maternal and neonatal outcomes. J of Hainan Medical University 2011;17(6):811-813. [14] Hodnett ED, Stremler R, Halpern SH.Repeated hands-and-knees positioning during labour: a randomized pilot study. PeerJ 2013;12;1:e25. [15]Machin D, Campbell M, Fayers P, Pinol A. Sample size tables for clinical studies. 2nd ed. Oxford: Blackwell Science;1997. [16]King TL, Pinger W.Evidence-based practice for intrapartum care: the pearls of midwifery. J Midwifery Womens Health 2014 ;59(6):572-85. [17]Kopas ML.A review of evidence-based practices for management of the second stage of labor. J Midwifery Womens Health 2014;59(3):264-76. [18]Tuuli MG, Frey HA, Odibo AO, et al.Immediate compared with delayed pushing in the second stage of labor: a systematic review and meta-analysis. Obstet Gynecol 2012 ;120(3):660-8. [19]Ceriani Cernadas JM. Early versus delayed umbilical cord clamping in preterm infants: RHL commentary (last revised: 7 March 2006). The WHO Reproductive Health Library; Geneva: World Health Organization. [20]Abalos E. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes : RHL commentary (last revised: 2 March 2009). The WHO Reproductive Health Library; Geneva: World Health Organization. [21]McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database Syst Rev 2008;2: CD004074. [22] LaCross A, Groff M, Smaldone A.Obstetric anal sphincter injury and anal incontinence following vaginal birth: a systematic review and meta-analysis. J Midwifery Womens Health 2015 ;60(1):37-47. [23]World Health Organization. Care in normal birth: a practical guide. Unpublished document WHO/FRH/MSM/96.24. Geneva, World Health Organization 1996. [24] Michel SC, Rake A, Treiber K, Seifert B, Chaoui R, Huch R, Marincek B, et al. MR Obstetric Pelvimetry: Effect of Birthing Position on Pelvic Bony Dimensions. AJR Am J Roentgenol 2002; 179 4 :1063–7. [25]Gupta JK, Hofmeyr GJ, Smyth R. Position in the second stage of labor for Women without epidural anesthesia. Cochrane Database Syst Rev 2004;1:CD002006
15
ACCEPTED MANUSCRIPT Comparing maternal and neonatal outcomes between hands-and-knees delivery position and supine position Short title: Hands-and-knees position delivery reduce episiotomy
Experimental group
Control group
(hands-and-knees position) n =446 67
2
68
n =440
M AN U
1
3 4
62 55
62
62
50
50
11
11
16
16
6
6
40
40
55
55
11
16
16
Total
446
440
8 9
AC C
10
EP
7
TE
6
67
55
D
5
(supine position)
SC
Code of the hospitals
RI PT
Table 1 Distribution of participants from each hospital (n = 886)
ACCEPTED MANUSCRIPT Table 2 Demographic and clinical characteristics of participants (n =886) Control position
t
P
( ±s)（n=446）
( ±s)（n =440）
Age
25.93±3.88
26.46±4.19
1.92
0.05
Pregnant weeks
39.57±1.39
39.22±2.27
2.77
0.06
Neonatal weight(g)
3304.01±438.84
3266.12±431.27
1.29
0.19
Apgar score- 1 min
9.76±0.63
9.72±0.71
1.02
0.30
Apgar score -5min
9.99±0.11
9.97±0.19
1.48
0.13
0.63
0.52
SC
M AN U
189.28±91.38
193.17± 90.3
EP
TE
D
Postpartum bleeding amount (ml)
RI PT
Experimental group
AC C
Table 3 Comparison of various perineum conditions between groups (n = 886) Hands-and-knees
Supine position
Perineum conditions
Fetal macrosomia Primipara
Neonatal asphyxia Intact perimium
P
position [n (%)]
[n (%)]
12(2.6)
10(2.2)
0.171
0.050
291(66.1)
0.172
0.681
301(67.5) 7 (1.6) 148（33.2）
10 (2.3)
0.582
0.446
65（14.8）
41.114
