Maternal posture for fetal malposition to improve labour and birth outcomes for mothers and their infants

Abstract

Aim: To assess current evidence-based practice for fetal malposition in labour; to investigate the incidence and outcomes of fetal malposition in New Zealand; and to assess the feasibility of a randomised controlled trial (RCT) of maternal posture for fetal malposition to improve maternal and infant health outcomes. Methods: A Cochrane systematic review of maternal posture for fetal malposition assessed its efficacy on health outcomes. A retrospective cohort study reviewed records and compared outcomes of occiput-posterior/transverse and occiput-anterior fetal position in labouring women at Auckland Hospital in 2018. A mixed method study using web-based surveys and focus groups (midwives) assessed pregnant women and midwives’ knowledge and views on fetal malposition and the acceptability of a future RCT of maternal posture. Findings: Hands and knees and lateral postures had little/no effect on operative birth, serious neonatal morbidity and other outcomes in the systematic review. However, the evidence was judged of low/very-low certainty due to risk of bias, heterogeneity and/or imprecision. Two-thirds of the retrospective cohort of women had fetal malposition and a quarter persisted till birth. Malposition was associated with body mass index ≥30, right-sided fetus, oxytocin augmentation, epidural-use, longer mean first-stage labour, reduced normal birth and increased caesarean section. Surveyed midwives mostly (80%) thought posture affects fetal position, utilise postural changes during labour, would recommend posture if caesareans reduced, and would collaborate with a trial. Focus-group participants (n=19) linked participation to relevance, practice flexibility and knowledge/skill development. One-quarter thought the Sims posture difficult for fetal monitoring. Of 206 surveyed pregnant women, 76% knew of malposition but only 28% were aware of postural approaches to care. 37% would participate in an RCT but half were unsure primarily related to comfort concerns, and half would consult their partner first. Conclusions: Further research is needed of hands and knees and lateral postures, including semi-prone and/or same-side-as-fetus postures. Labour interventions facilitating anterior fetal rotation could potentially improve the health of mothers. New Zealand midwives practice flexibility of posture. Trial participation by women and midwives may be enhanced by provision of some free movement, comfort measures and increased awareness of malposition and the role of posture.