Hands and knees position ineffective for fetal rotation, improves comfort

1. In women presenting with a malpositioned fetus (occiput posterior), women randomized to hands and knees positioning in labor were no more likely to experience fetal rotation compared to controls.

2. Women randomized to the hands and knees position for at least 10 minutes were more likely to report an increase in comfort level compared to controls.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Occiput anterior fetal head positioning in labor helps facilitate vaginal delivery. While babies are born face up (occiput posterior) every day, vaginal delivery is most likely to occur when fetuses descend into the maternal pelvis face down (occiput anterior, OA) because OA position permits alignment of the largest parts of the fetal vertex with the largest diameter of the maternal pelvis. During the first stage of labor, most babies will naturally settle into the left or right OA position, meaning that the fetal occiput, or back of the head, is oriented just lateral to the most ventral portion of the maternal pubic symphysis. Approximately 25 percent will descend in the occiput posterior position (with the fetal occiput oriented just lateral to the maternal sacrum) and remain this way during the first stage of labor whereas only 10% of fetuses remain in this position through the second stage of labor, or until delivery. Studies have associated the occiput posterior position with complications including prolonged labor, maternal exhaustion, fetal distress, operative delivery, and cesarean section. Many practitioners believe that hands and knees positioning helps rotate the fetus, but there is limited data to support this practice. In 2007, a Cochrane review concluded that further studies were needed. In this randomized controlled trial, researchers assessed the efficacy of the hands and knees laboring position at correcting persistant occiput posterior position.

Among women with persistent occiput posterior fetuses, those randomized to laboring in the hands and knees position for a minimum of 10 minutes did not experience higher rates of fetal rotation to occiput anterior compared to controls. Strengths included parsimonious randomized controlled design and enrollment of nearly 500 women. Limitations included the fact that the minimum duration of the hands and knees position in the intervention group was only 10 minutes, which may bias results toward the null since many purport that the position must be held over numerous contractions to affect fetal rotation. Replication of findings in a randomized trial where women held the hands and knees position for a longer duration of labor would confirm the findings presented herein.

Click to read the study in BJOG

Click to read the study commentary in BJOG

Relevant Reading: Hands and knees posture in late pregnancy or labour for fetal malposition [Cochrane Review]

In-Depth [randomized controlled trial]: Women presenting to in the first stage of labor with a fetus in the occiput posterior position were randomized to an intervention group that was invited to take a hands and knees position for at least 10 minutes (n=220) or a control group that received the standard care (n=219). Fifteen minutes after randomization, both groups were asked to complete short questionnaire on perceived pain and comfort. The primary outcome was rotation of the fetal head to the desired occiput anterior position, confirmed by ultrasound one hour after randomization.

There was no difference in rotation to the occiput anterior position between the intervention and control groups (17% vs 12%; RR: 1.5; 95%CI 0.9-2.4). However, a larger proportion of women randomized to the intervention group reported improvement in comfort levels compared to controls (34% vs 19%, p = 0.02).

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