Background 1

1. How does positioning in the second stage of labor affect birthing trauma to the mother?Lauren Kessing, Sam Parmenter, Allison Reiland, Brittany Rowe, Allison SilverIndiana University School of Nursing Background1 Women giving birth on a birth seat4 Child Birth in Squatting Position3 Purpose of study: The purpose of this study, according to Thies- Lagergren, Kvist, Christensson, Hildingsson (2011), demonstrated by the hypothesis is; “that the use of a birthing seat during the second stage of labor, for healthy nulliparous women, decreases the number of instrumentally assisted births and may thus counterbalance any increase in perineal trauma and blood loss.” Methods: This study is a non-blinded randomized controlled trial. The experimental group was to give birth on a birth seat and the control group was to give birth in any position but birth on the seat. The study was conducted in Sweden in two separate hospitals. A total of 920 women participated who met inclusion criteria and gave written consent. Inclusion criteria were sufficient understanding of Swedish language, normal pregnancy, single fetus, cephalic presentation, spontaneous inception of labor between 37 and 41 weeks gestation, BMI under 30%, minor gestational diabetes not requiring treatment, those that have had a C-section but are now panning a vaginal birth, and those who had a spontaneous rupture without contractions for over 24 hours that were induced. The central variable was the comparison of the number of vaginal births that required instrumental assistance between the two groups. The secondary outcome measures comprised of the extent of perineal trauma, perineal edema, maternal blood loss and postpartum hemoglobin (Hb) levels. Once data was collected Analysis was done by PASW version 18.0. Continuous data mean values was compared using independent samples t- tests. The relative risk, with a CI of 95%, was calculated for Categorical data. Findings: The birth seat did not reduce the number of instrumental vaginal births. There was an increase in blood loss when using the birth seat compared to the control group. Giving birth on a birth seat had no adverse consequences for perineal outcomes and may be protective against episiotomies. Implications: The authors noted a few limitations. There may have been losses of eligibility due to a time span between selection for participation and birth and an erroneous inclusion of women who met exclusion criteria. There was also non-compliance with the intervention (sitting on birth stool) and it was noted that the results should be interpreted with caution. Also small differences between the groups are insufficient to make strong decisions due to low statistical power. However, it was indicated that that even with low power, the results can add to future meta-analysis to find more solid evidence that answer questions about birthing positions. Practice should not be changed as the result of this study alone. Level of evidence 2: Evidence from at least one well-designed RCT Effective positioning is known to speed labor and reduce discomfort by aligning the baby properly, reducing area-specific pressure and reducing unnecessary muscle effort. There has been research that shows non-supine positioning can lead to lower levels of reported back pain, reduced pain during pushing, fewer perineal tears and easier pushing. Beir (2012) reported that 65.9% of women in the U.S. use the lithotomy and semi-sitting position during the second stage of labor and 4% of U.S. women reported using the squatting or sitting position. The prevalence of the use the lithotomy position is much higher in the US than in other countries that utilize alternative birthing positions. Research shows that there is an increased amount of benefits in birthing in a non-supine position in relation to reducing birth trauma to the mother. However recent research has begun to show that this is not may not always be the case. The studies we have chosen compare risks and benefits of various birthing positions and their effects on birth trauma. Purpose of study: Nasir, Korejo and Noorani (2007) sought to identify if the squatting position had any potential risks or benefits when compared with the traditional supine position. Methods: The study took a year to conduct and was held at the Department of Obstetrics and Gynaecology, Jinnah Postgraduate Medical Center. Two hundred patients were selected with similar socio-economic standings, ante partum and intrapartum status. Patients were only considered if they were in active labor with cephalic presentation and 37+ weeks gestations. Exclusions included women with: scarring, fever, multiple gestation, malpresentation or any problem with fetus. After receiving informed consent, the researchers used random selection and placement into two groups. Stage one the patients were ambulatory. Stage two, the first group were in squatting position while the second group were supine in the lithotomy position. Finally, stage three, both groups completed their birth in the supine position. Findings: No difference was seen in the need of an episiotomy in both groups. Extension of the episiotomy was needed in 7% of the second group (non squatting women). Forceps were used with 11% of squatting women and 24% in non squatting women. Two cases of shoulder dystocia, 1% postpartum haemorrhage, 4% retained placenta in non squatting women and none of the above were seen in squatting women. Also, one patient in the non squatting position had to have a caesarean section due to persistent occipito posterior position. Implications: This study reveals that choosing the supine position for birth could increase the woman's chance for episiotomies and instrumental deliveries. It is also noted that women who use the squatting method tend to experience less pain. More trials need to be conducted to support the evidence, a 200 women sample is not enough. Also, different stages of labor were squatting is introduced and the position of the baby could be trailed. Level of evidence 2: Evidence from at least one well-designed RCT Position in the second stage of labour2 Purpose of study: Gupta, Hofmeyr & Smyth (2009) assess benefits and risks of different positions during the second stage of labor Methods: The authors reviewed the Cochrane Pregnancy and Childbirth Group Trials Register from September 30, 2005. They selected trials that used randomized or quasi-randomized research designs and implemented appropriate follow up that compared various positions of pregnant women in the second stage of labor. The research women had to meet a specific inclusion criteria and once the a rticle meet this criteria, they were extracted and reviewed for comparison. Findings: Benefits of using the upright birthing position during the second stage of labor include shorter second stage labor, reduction in episiotomies, fewer abnormal fetal heart rate patterns, and reduction of pain. However, there is a possible increased risk of blood loss of greater than 500 ml when using the upright position. Implications: The author suggests that the findings from the review were tentative and should be evaluated with greater certainty using methodologically stringent trials. For now, women should be in charge of their birthing position and be able to decide which position is most comfortable to them. Level of evidence 1: Systematic review or meta-analysis of all relevant randomized controlled trials (RCTs), or evidence-based clinical practice guidelines based on systematic reviews of RCTs Discussion When compared to lithotomy positions, alternative positions have been shown to have greater benefits and fewer risks. Lateral and upright positions have been found to reduce the length of 2nd stage labour, reduce in the use of assistive equipment, reduction in tears and episiotomies, reduced pain, and reduced abnormal fetal heart tones compared to supine positions. One major risk of non-supine positions is the increased amount of blood loss, up to 500 mL, over the lithotomy position but not greater than 1000 mL total. More comprehensive and new studies should be conducted to confirm the research. These studies should take place within a hospital setting in the United States to see the direct effects of birthing positions, such as side-lying, lateral, use of birthing seats, upright, and hands and knees. It would be beneficial to study why mothers are not utilizing alternative birthing positions when evidence based practice proves its superiority over the lithotomy position. Studying specific positions and their relation to improving the incidence of birthing traumas will give women more confidence when making decisions regarding their labor and delivery plan. This research will allow nurses to implement evidence based practice when educating women in the antepartum period to develop their personal birthing plans. While assisting women with alternative birthing positions, support would encourage women to take advantage of the most comfortable position for their specific needs. To implement these changes hospitals would need to provide more equipment to facilitate the use of alternative birthing positions. References ¹ Beir, C. (2012). Best Labor and Birth Positions. Giving Birth Naturally. Retrieved from http://www.givingbirthnaturally.com/ ² Gupta, J., Hofmeyr, G., & Smyth, R. (2007). Position in the second stage of labour for women without epidural anaesthesia. The Cochrane Library, 4, 1-61. ³Nasir, A., Korejo, R., & Noorani, K. (2007). Child Birth in Squatting Position. The Journal of the Pakistan Medical Association , 57(1), 19-22. 4Thies-Lagergren L., Kvist L. J., Christensson K., Hildingsson I. (2011). No reduction in instrumental vaginal births and no increased risk for adverse perineal outcome innulliparouswomen giving birth on a birth seat: results of a Swedish randomized controlled trial. BMC Pregnancy and Childbirth 2011, 11:22. doi:10.1186/1471-2393-11-22 c http://www.birthrite.com.au/eng/products/floor_studio/components/birthing_seat/index.htm