Mini-CAT Assignment

1. Mini-CAT Assignment Jeanine Alokush Maria Barak Christopher Inderjit Mariyanthie Linaris Chaya Wertman

2. You are doing your OB/Gyn rotation and you notice that most of the women are giving birth in the lithotomy position at the encouragement of the physicians. You recall that one of the nurse midwives commented that other positions are less likely to lead to delivered with forceps or a vacuum. What is the evidence on this question? Clinical Scenario

3. Does non-lithotomy positioning reduce the incidence of labor complications in women during the second stage of labor compared to lithotomy positioning? Clinical Question

4. PICO Search Terms

5. 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 Search Strategy

6. 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., 2012] Position in the Second Stage of Labour for Women Without Epidural Anaesthesia: A Randomized Control Trial. [Gupta et. al, 2017] Childbirth in Squatting Position [Nasir, Korejo, & Noorani, 2007] A meta-analysis of upright positions in the second stage to reduce instrumental deliveries in women with epidural analgesia Birth Position, Accoucher, and Perineal Outcomes: Informing Women About Choices for Vaginal Birth. [A. Shorten, J. Donsante & B. Shorten , 2002] Articles

7. Level of Evidence: Randomized Control Trial Sample/Setting: labor and delivery unit at Parkland Hospital 214 women meeting inclusion criteria randomized to bed delivery without stirrups or with stirrups: 108 women without, 106 with stirrups Primary outcome: Any perineal lacerations first through fourth-degree graded Secondary outcomes : obstetric outcomes, characteristics/variables that might impact perineal lacerations 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. 2012

8. A Randomized Trial of Birthing With and Without Stirrups Findings: 82 (76%) randomized to no stirrups - one or more perineal lacerations 83 (78%) randomized with stirrups - one or more perineal lacerations p=.8. No significant differences in secondary outcomes There are no apparent advantages or disadvantages, when delivering in bed without stirrups Limitations: • 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

9. Authors (Date): Janesh K.Gupta, Akanksha Sood, G. Justus Hofmeyr, Joshua P. Vogel (2017) Level of Evidence: Randomized Control Trial Sample/Setting: 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 Position in the Second Stage of Labour for Women Without Epidural Anaesthesia: A Randomized Control Trial.

10. Outcome(s) Studied: To determine the risk/benefit of different birth positions during second stage of labor without epidural anaesthesia. Key Findings: Reduction in duration of second stage of labor Fewer women had assisted delivery Blood Loss Limitations and Biases Funding Sources Blinding High Heterogeneity and wide Confidence Intervals Position in the Second Stage of Labour for Women Without Epidural Anaesthesia: A Randomized Control Trial.

11. A meta-analysis of upright positions in the second stage to reduce instrumental deliveries in women with epidural analgesia Level of Evidence: Meta analysis of 2 Randomized control trials, with a total sample size of 281. Criteria: -Trail eligibility: randomized control trials of women with epidural analgesia that compared upright and recumbent positions during the second stage of labor -Pre-specified study outcomes: The primary outcome was instrumental delivery. Secondary maternal outcomes included cesarean section, length of the second stage, any fetal malposition, perineal trauma such as tears, postpartum hemorrhages, pain relief, satisfaction with care, and longer term outcomes, such as urinary or fecal incontinence or dyspareunia

12. A meta-analysis of upright positions in the second stage to reduce instrumental deliveries in women with epidural analgesia Results/key outcomes: • There were large, but statistically non-significant, reductions in the risks of instrumental and cesarean deliveries for upright versus recumbent positions in the second stage of labor. • There was a corresponding increase in spontaneous vaginal births (RR ¼ 1.14, 95% CI ¼ 0.98– 1.32). • Golara et al. reported that there was a non-significant reduction in perineal trauma for women in upright positions, compared to that for women in recumbent positions: 64 % versus 83%. • Golara et al. reported a significant reduction in the median length of the second stage of labor (109 min for upright and 133 minute for recumbent.

13. A meta-analysis of upright positions in the second stage to reduce instrumental deliveries in women with epidural analgesia Limitations: - Small population size -Was studied in Australia /study was from 2005 -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 -The durations for both groups were different, where one group reported the median duration of the second stage only and the other reported the mean total length of labor.

14. Childbirth in Squatting Position Authors (Date): • Ayesha Nasir, Razia Korejo, and K. J. Noorani(2007) Level of Evidence: • Randomized Control Trial Sample/Setting: • 200 women of more than 37 weeks of gestation with similar antepartum, intrapartum, and socioeconomic conditions in active labor • Only women with cephalic presentation and longitudinal lie were included • Randomly sorted so 100 women were in Group A and 100 were in Group B • Sampled women between January 1, 1999 and January 31, 2000 at the Department of Obstetrics and Gynecology at the Jinnah Postgraduate Medical Centre in Karachi, Pakistan

15. Childbirth in Squatting Position Outcomes Studied: • Application/extension of episiotomies • Paraurethral tears • Perineal tears • Shoulder dystocia • Retained placenta • Postpartum hemorrhage • Forceps application (instrumental delivery) • Neonatal outcomes

16. Childbirth in Squatting Position Results: • 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), or postpartum hemorrhage (p = .5) • Significantly fewer instrumental deliveries in group A (p < .05**) • No significant difference in neonatal outcomes Limitations: • Small sample size • Studied in Pakistan • Squatting vs other upright positions • Slightly dated study

17. Birth Position, Accoucher, and Perineal Outcomes: Informing Women About Choices for Vaginal Birth Authors (Date): • Allison Shorten, Jacki Donsante, and Brett Shorten (2002) Level of Evidence: • Retrospective Cohort Sample/Setting: • 2891 normal vaginal births in a regional teaching hospital in new south wales, Australia • women were 13-45 years of age (mean=27 years) and included both nulliparous and multiparous • mean duration of second stage of labor was a little more than 30 minutes • midwives and obstetricians delivered about 1447/2981 births

18. Birth Position, Accoucher, and Perineal Outcomes: Informing Women About Choices for Vaginal Birth Outcome(s) Studied: • The effect of birthing position on perineal outcome: intact or graze/tear not sutured, 1st, 2nd, 3rd degree tears, labial tear and episiotomy. • Birthing positions included: lateral, all fours, kneeling, standing, and squatting. Results: • Birthing position did affect rate of episiotomy: nulliparas ( p < 0.005) and multiparas ( p < 0.001). • Significant effects were found for birth position on the risk of tears requiring suture: nulliparas (p < 0.10) and multiparas (p < 0.001). • However for having an intact perineum, birth position was significant in the case of multiparas only (p < 0.001). • Of all positions, the lateral position had the highest intact rate (66.6%) and also had below average episiotomy rate.

19. Birth Position, Accoucher, and Perineal Outcomes: Informing Women About Choices for Vaginal Birth Limitations: • Took place in Australia • Done in one hospital • Took place in 2002 • Not everyone was birthed by same professional, some were birthed by midwives, obstetricians, other physicians, or a student midwife. For “publicly insured women,'' the birth is conducted by midwives, student midwives, or obstetric registrars. Specialist obstetricians attended birth for “privately insured women.”

20. While there is a good deal of conflict in previously published literature, most research illustrates that there is no significant advantage of lithotomy positioning. A majority of research demonstrates some degree of improved maternal outcome in non-lithotomy positioning during the second stage of labor. Conclusions

21. There seems to be no benefit to lithotomy positioning over other positioning in labor 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 Looking to the future: More research, specifically in the United States, should be conducted with larger sample sizes Clinical Bottom Line

22. References • Corton, M. M. 1., Lankford, J. C., Ames, R., McIntire, D. D., Alexander, J. M., & Leveno, K. J. (2012). A randomized trial of birthing with and without stirrups. American Journal of Obstetric Gynecology; 207 (2), 133.e1 - 133.e5. PMID: 22840725. • Gupta, J. K., Sood, A., Hofmeyr, G. J., & Vogel, J. P. (2017). Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews; 5 (CD002006). PMID: 28539008. • Nasir, A., Korejo, R., & Noorani, K. J. (2007). Childbirth in squatting position. Journal of Pakistani Medical Association; 57 (1), 19 - 22. PMID: 17319414. • Roberts, C. L., Algert, C. S. 3., Cameron, C. A. 1, & Torvaldsen, S. (2005). A meta analysis of upright positions in the second stage to reduce instrumental deliveries in women with epidural analgesia. Acta Obstet Gynecol Scand; 84, 794 - 798. PMID: 16026407. • Shorten, A., Donsante, J., & Shorten, B. (2002). Birth position, accoucheur, and perineal outcomes: informing women about choices for vaginal birth. Birth; 29 (1), 18 - 27. PMID: 11843786.