Get access

Randomized Controlled Trial of Hands-and-Knees Positioning for Occipitoposterior Position in Labor

Authors

  • Robyn Stremler RN, PhD,

    Search for more papers by this author
    • a

      The study was supported by grants from the Canadian Institutes of Health Research (CIHR), Ottawa, Ontario (grant MCT 50421), the American Nurses Foundation/Sigma Theta Tau International, Washington, DC, and Indianapolis, Indiana (Nurse Scholar award 99–123), the Faculty of Nursing, University of Toronto, and the Registered Nurses Foundation of Ontario, Toronto. Robyn Stremler currently holds a Randomized Controlled Trials Mentoring Award from CIHR, and at the time of the study she held a CIHR Fellowship and Bonnie Stevens held a Career Scientist Award (Ontario Ministry of Health).

  • Ellen Hodnett RN, PhD,

    1. Robyn Stremler is Clinician Scientist and Andrew Willan is Senior Scientist, The Hospital for Sick Children, Toronto, Ontario; Ellen Hodnett and Bonnie Stevens are Professors and Julie Weston is Senior Research Coordinator, Faculty of Nursing, University of Toronto, Toronto, Ontario; and Patricia Petryshen is Assistant Deputy Minister, Ministry of Health Services, Victoria, British Columbia, Canada.
    Search for more papers by this author
  • Patricia Petryshen RN, PhD,

    1. Robyn Stremler is Clinician Scientist and Andrew Willan is Senior Scientist, The Hospital for Sick Children, Toronto, Ontario; Ellen Hodnett and Bonnie Stevens are Professors and Julie Weston is Senior Research Coordinator, Faculty of Nursing, University of Toronto, Toronto, Ontario; and Patricia Petryshen is Assistant Deputy Minister, Ministry of Health Services, Victoria, British Columbia, Canada.
    Search for more papers by this author
  • Bonnie Stevens RN, PhD,

    1. Robyn Stremler is Clinician Scientist and Andrew Willan is Senior Scientist, The Hospital for Sick Children, Toronto, Ontario; Ellen Hodnett and Bonnie Stevens are Professors and Julie Weston is Senior Research Coordinator, Faculty of Nursing, University of Toronto, Toronto, Ontario; and Patricia Petryshen is Assistant Deputy Minister, Ministry of Health Services, Victoria, British Columbia, Canada.
    Search for more papers by this author
  • Julie Weston RN, MSc,

    1. Robyn Stremler is Clinician Scientist and Andrew Willan is Senior Scientist, The Hospital for Sick Children, Toronto, Ontario; Ellen Hodnett and Bonnie Stevens are Professors and Julie Weston is Senior Research Coordinator, Faculty of Nursing, University of Toronto, Toronto, Ontario; and Patricia Petryshen is Assistant Deputy Minister, Ministry of Health Services, Victoria, British Columbia, Canada.
    Search for more papers by this author
  • Andrew R Willan PhD

    Corresponding author
    1. Robyn Stremler is Clinician Scientist and Andrew Willan is Senior Scientist, The Hospital for Sick Children, Toronto, Ontario; Ellen Hodnett and Bonnie Stevens are Professors and Julie Weston is Senior Research Coordinator, Faculty of Nursing, University of Toronto, Toronto, Ontario; and Patricia Petryshen is Assistant Deputy Minister, Ministry of Health Services, Victoria, British Columbia, Canada.
    Search for more papers by this author

* Robyn Stremler, RN, PhD, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada, M5G 1X8.

Abstract

ABSTRACT: Background:Hands-and-knees positioning during labor has been recommended on the theory that gravity and buoyancy may promote fetal head rotation to the anterior position and reduce persistent back pain. A Cochrane review found insufficient evidence to support the effectiveness of this intervention during labor. The purpose of this study was to evaluate the effect of maternal hands-and-knees positioning on fetal head rotation from occipitoposterior to occipitoanterior position, persistent back pain, and other perinatal outcomes. Methods:Thirteen labor units in university-affiliated hospitals participated in this multicenter randomized, controlled trial. Study participants were 147 women laboring with a fetus at ≥37 weeks’ gestation and confirmed by ultrasound to be in occipitoposterior position. Seventy women were randomized to the intervention group (hands-and-knees positioning for at least 30 minutes over a 1-hour period during labor) and 77 to the control group (no hands-and-knees positioning). The primary outcome was occipitoanterior position determined by ultrasound following the 1-hour study period and the secondary outcome was persistent back pain. Other outcomes included operative delivery, fetal head position at delivery, perineal trauma, Apgar scores, length of labor, and women's views with respect to positioning. Results:Women randomized to the intervention group had significant reductions in persistent back pain. Eleven women (16%) allocated to use hands-and-knees positioning had fetal heads in occipitoanterior position following the 1-hour study period compared with 5 (7%) in the control group (relative risk 2.4; 95% CI 0.88–6.62; number needed to treat 11). Trends toward benefit for the intervention group were seen for several other outcomes, including operative delivery, fetal head position at delivery, 1-minute Apgar scores, and time to delivery. Conclusions:Maternal hands-and-knees positioning during labor with a fetus in occipitoposterior position reduces persistent back pain and is acceptable to laboring women. Given this evidence, hands-and-knees positioning should be offered to women laboring with a fetus in occipitoposterior position in the first stage of labor to reduce persistent back pain. Although this study demonstrates trends toward improved birth outcomes, further trials are needed to determine if hands-and-knees positioning promotes fetal head rotation to occipitoanterior and reduces operative delivery. (BIRTH 32:4 December 2005)

Ancillary