Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior) (Review)

Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior) (Review) Hunter S, Hofmeyr GJ, Kulier R This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2009, Issue 1 http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S HEADER....................................... 1 ABSTRACT...................................... 1 PLAIN LANGUAGE SUMMARY.............................. 2 BACKGROUND.................................... 2 OBJECTIVES..................................... 2 METHODS...................................... 2 RESULTS....................................... 3 DISCUSSION..................................... 4 AUTHORS CONCLUSIONS............................... 4 ACKNOWLEDGEMENTS................................ 4 REFERENCES..................................... 5 CHARACTERISTICS OF STUDIES............................. 5 DATA AND ANALYSES.................................. 9 Analysis 1.1. Comparison 1 Hands and knees posture in pregnancy, Outcome 1 Persistent lateral/posterior fetal position. 9 Analysis 1.2. Comparison 1 Hands and knees posture in pregnancy, Outcome 2 Posterior position at delivery.... 10 Analysis 1.3. Comparison 1 Hands and knees posture in pregnancy, Outcome 3 Epidural analgesia....... 11 Analysis 1.4. Comparison 1 Hands and knees posture in pregnancy, Outcome 4 Caesarean section....... 11 Analysis 1.5. Comparison 1 Hands and knees posture in pregnancy, Outcome 5 Assisted delivery........ 12 Analysis 2.1. Comparison 2 Hands and knee posture during labour, Outcome 1 Persistent lateral/posterior fetal position. 12 Analysis 2.2. Comparison 2 Hands and knee posture during labour, Outcome 2 Lateral/posterior position at delivery. 13 Analysis 2.4. Comparison 2 Hands and knee posture during labour, Outcome 4 Operative delivery....... 13 Analysis 2.5. Comparison 2 Hands and knee posture during labour, Outcome 5 Perineal trauma........ 14 Analysis 2.6. Comparison 2 Hands and knee posture during labour, Outcome 6 Apgar scores< 7 at 1 minute.... 14 Analysis 2.7. Comparison 2 Hands and knee posture during labour, Outcome 7 Apgar scores > 7 at 5 mins.... 15 WHAT S NEW..................................... 15 HISTORY....................................... 15 CONTRIBUTIONS OF AUTHORS............................. 16 DECLARATIONS OF INTEREST.............................. 16 SOURCES OF SUPPORT................................. 16 INDEX TERMS.................................... 16 i

[Intervention Review] Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior) Sandra Hunter 1, G Justus Hofmeyr 2, Regina Kulier 3 1 Effective Care Research Unit, Eastern Cape Department of Health/University of the Witwatersrand/Fort Hare, East London, South Africa. 2 Department of Obstetrics and Gynaecology, East London Hospital Complex, University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of Health, East London, South Africa. 3 Geneva Foundation for Medical Education and Research, Geneva, Switzerland Contact address: Sandra Hunter, Effective Care Research Unit, Eastern Cape Department of Health/University of the Witwatersrand/Fort Hare, East London, South Africa. s.l.hunter@hotmail.com. Editorial group: Cochrane Pregnancy and Childbirth Group. Publication status and date: Edited (no change to conclusions), published in Issue 1, 2009. Review content assessed as up-to-date: 29 July 2007. Citation: Hunter S, Hofmeyr GJ, Kulier R. Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior). Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD001063. DOI: 10.1002/14651858.CD001063.pub3. Background A B S T R A C T Lateral and posterior position of the baby s head (the back of the baby s head facing to the mother s side or back) may be associated with more painful, prolonged or obstructed labour and difficult delivery. It is possible that certain positions adopted by the mother may influence the baby s position. Objectives To assess the effects of adopting a hands and knees maternal posture in late pregnancy or during labour when the presenting part of the fetus is in a lateral or posterior position compared with no intervention. Search methods We searched the Cochrane Pregnancy and Childbirth Group s Trials Register (July 2007) and the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 2). Selection criteria Randomised trials of hands and knees maternal posture compared to other postures or controls. Data collection and analysis Two review authors assessed trial eligibility and quality. Main results Three trials (2794 women) were included. In one trial (100 women), four different postures (four groups of 20 women) were combined for the comparison with the control group of 20 women. Lateral or posterior position of the presenting part of the fetus was less likely to persist following 10 minutes in the hands and knees position compared to a sitting position (one trial, 100 women, relative risk (RR) 0.26, 95% confidence interval (CI) 0.18 to 0.38). In a second trial (2547 women), advice to assume the hands and knees posture for 10 minutes twice daily in the last weeks of pregnancy had no effect on the baby s position at delivery or any of the other pregnancy 1

outcomes measured. The third trial studied the use of hands and knees position in labour and involved 147 labouring women at 37 or more weeks gestation. Occipito-posterior position of the baby was confirmed by ultrasound. Seventy women, who were randomised in the intervention group, assumed hands and knees positioning for a period of at least 30 minutes, compared to 77 women in the control group who did not assume hands and knees positioning in labour. The reduction in occipito-posterior or -transverse positions at delivery and operative deliveries were not statistically significant. There was a significant reduction in back pain. Authors conclusions Use of hands and knees position for 10 minutes twice daily to correct occipito-posterior position of the fetus in late pregnancy cannot be recommended as an intervention. This is not to suggest that women should not adopt this position if they find it comfortable. The use of position in labour was associated with reduced backache. Further trials are needed to assess the effects on other labour outcomes. P L A I N L A N G U A G E S U M M A R Y Assuming the hands and knees posture in late pregnancy does not improve pregnancy outcomes but use in labour is beneficial. The best position for babies during birth is head down, with the back of their head facing forward. When babies lie with the back of their head towards the mothers side (lateral) or towards the mothers back (posterior), the labour may be longer and more painful. The review of three trials (2794 women) found that assuming the hands-knees position for ten minutes helped the baby to modify position at the time, but suggesting women assume the hands and knees position for ten minutes twice daily during late pregnancy had no effect on longer-term outcomes in labour. Using this position during labour reduced backache. B A C K G R O U N D The optimal position of the baby during labour and delivery is with the head presenting and the back of the head directed anteriorly (occipito-anterior position). Lateral and posterior positions, with the back of the head directed to the mother s side or back respectively, may be associated with more painful labour, prolonged labour, obstructed labour and difficult delivery. A theoretical basis exists for the possibility that maternal posture may influence the baby s position. It is therefore worthwhile to investigate the effectiveness of maternal postural interventions for lateral and posterior positions of the baby. A physical theory for the mechanism of action of postural management of fetal malpositions and malpresentations has been put forward (Andrews 2004). The hands and knees posture, with the women kneeling forwards on her hands and knees, has been suggested as a method of promoting a favourable position for the baby. O B J E C T I V E S To determine, from the best available evidence, the effects of adopting the hands and knees maternal posture in late pregnancy or during labour, when the baby s head is in a lateral or posterior position, or to prevent such positions. M E T H O D S Criteria for considering studies for this review Types of studies Clinical trials comparing hands and knees maternal posture with control postures; random allocation to treatment and control groups with adequate allocation concealment; violations of allocated management and exclusions after allocation not sufficient to materially affect outcomes. Types of participants Women with lateral or posterior fetal positions in late pregnancy or labour, or women with any fetal positions (preventive). Types of interventions Variations of the hands and knees posture to prevent or correct fetal malposition, versus alternative postures. 2

Types of outcome measures Change in fetal position; fetal position during labour and at delivery; duration of labour; pain scores; analgesia used; method of delivery; perinatal outcomes; maternal satisfaction. Outcomes included if clinically meaningful; reasonable measures taken to minimise observer bias; missing data insufficient to materially influence conclusions; data available for analysis according to original allocation, irrespective of protocol violations; data available in a format suitable for analysis. Search methods for identification of studies including differential withdrawal of participants or loss to follow up from different groups; and analysis of randomised participants in randomised groups (analysis by intention to treat). We included individual outcome data in the analysis if they met the prestated criteria in Types of outcome measures. We processed included trial data as described in Higgins 2006. We extracted data from the sources and entered them onto the Review Manager (RevMan 2003) computer software, checked them for accuracy, and analysed them as above using the RevMan 2003 software. For dichotomous data, we calculated relative risks and 95% confidence intervals. For continuous data, weighted mean differences with 95% confidence intervals were to be used. Electronic searches We searched the Cochrane Pregnancy and Childbirth Group s Trials Register by contacting the Trials Search Co-ordinator (July 2007). The Cochrane Pregnancy and Childbirth Group s Trials Register is maintained by the Trials Search Co-ordinator and contains trials identified from: 1. quarterly searches of the Cochrane Central Register of Controlled Trials (CENTRAL); 2. monthly searches of MEDLINE; 3. handsearches of 30 journals and the proceedings of major conferences; 4. weekly current awareness search of a further 36 journals plus monthly BioMed Central email alerts. Details of the search strategies for CENTRAL and MEDLINE, the list of handsearched journals and conference proceedings, and the list of journals reviewed via the current awareness service can be found in the Search strategies for identification of studies section within the editorial information about the Cochrane Pregnancy and Childbirth Group. Trials identified through the searching activities described above are given a code (or codes) depending on the topic. The codes are linked to review topics. The Trials Search Co-ordinator searches the register for each review using these codes rather than keywords. We also searched CENTRAL (The Cochrane Library 2007, Issue 2) using hands-knees or (hands and knees). We did not apply any language restrictions. Data collection and analysis We evaluated the trials under consideration for methodological quality and appropriateness for inclusion according to the prestated selection criteria, without consideration of the results. We assessed the quality of the studies based on: allocation concealment (scored as adequate, unclear or inadequate); generation of random allocation sequence (adequate, unclear or inadequate); blinding of outcome assessment; completeness of data collection, R E S U L T S Description of studies See: Characteristics of included studies; Characteristics of excluded studies. See table of Characteristics of included studies. Risk of bias in included studies See table of Characteristics of included studies, particularly the Methods and Notes sections. In the study of Andrews 1983, the method of random assignment is not specified. In other respects the study is methodologically sound. Using palpation alone to determine outcome is subject to error, but as the evaluation was made blind to the group allocation, outcome assessment was probably unbiased. In the study of Kariminia 2004, telephone randomisation by an independent service was used. A discrepancy in the numbers allocated to each group (1292 versus 1255) in spite of using permutated blocks of size four for randomisation, is not accounted for. About 16% in the intervention group withdrew (compared to 3.5% in the control group). Almost half of the withdrawals in the intervention group were for reasons of pain, uncomfortable - which may be an indicator for the acceptability of the intervention. A further 9% withdrew for medical reasons other than preterm delivery (compared to none in the control group). However, analysis was by intention to treat. In the study of Stremler 2005, centrally controlled telephonebased computerised randomization included prognostic stratification for parity (nullipara or multipara) and anaesthesia used (epidural or not). A random block size between four and six was used. There was no record of withdrawals from the trial and compliance of women in the study group was said to be excellent. Clinicians who were involved in the telephone call in order to obtain group allocation were excluded from performing the final 3

ultrasound in order to obtain the primary outcome. This appeared to be the only measure carried out to ensure blinding. Effects of interventions We have included three trials (2794 women). The study of Andrews 1983 reported only short-term results following one episode of hands and knees posture. The results using four variations of the hands and knees posture were similar, and have been grouped together for the purpose of this review. Lateral or posterior position of the presenting part of the fetus was far less likely to persist following ten minutes in the hands and knees position than in a control position (sitting) (one trial, 100 women, relative risk (RR) 0.26, 95% confidence interval (CI) 0.18 to 0.38). The study of Kariminia 2004 reported clinical outcomes of pregnancy following instructions to use the hands and knees posture with pelvic rocking for 10 minutes, twice daily, for the last few weeks of pregnancy. There were no differences in position at delivery (one trial, 2547 women, RR 1.06, 95% CI 0.85 to 1.32) or any of the other outcomes measured. Stremler 2005 studied 147 women with occipito-posterior position during labour. Women in the study group were asked to assume the hands and knees position for at least 30 minutes over the initial hour, then as much as possible for the remainder of the labour. Persistent occipito-posterior or -lateral positions at delivery were 19/60 versus 26/62 respectively (RR 0.76, 95% CI 0.47 to 1.21). The secondary outcome of persistent back pain where values were recorded as the mean differences of pre-intervention and post-intervention scores (95% CI) showed a significant reduction in the intervention group. However, as standard deviations were not available, these data could not be entered into the analysis program. Visual Analog Scale (VAS), Present Pain Intensity (PPI) and Word descriptors were used as independent pain scores. malpresentation), withdrawals from the trial, and the fact that clinical assessment of fetal position in labour may be difficult. In the study of Stremler 2005, compliance to the intervention group was well maintained; it appeared that women used the hands and knees position during and after the allocated time up until delivery, and that the position was acceptable to the women. Larger trials are needed to determine whether the use of this posture improves other birth outcomes. A U T H O R S C O N C L U S I O N S Implications for practice Use of hands and knees posture for 10 minutes twice daily to correct occipito-posterior position of the fetus in late pregnancy cannot be recommended as an intervention. This is not to suggest that women should not adopt this position if they find it comfortable. The use of this position during labour was associated with a significant reduction in persistent back pain. Women may therefore be encouraged to use this position for comfort in labour. Implications for research Further research on the effects of hands and knees posture in late pregnancy to correct occipito-posterior positions does not appear to be justified. In view of the promising short-term effects of the technique and its simplicity, further trials are justified to determine whether encouraging the use of hands and knees posture during labour has any effect on the progress or outcome of labour. These outcomes should include a measure of pain experienced during labour, the duration of labour, the method of delivery, the baby s condition and maternal satisfaction. The assessment of fetal position by ultrasound would enhance the reliability of these results. D I S C U S S I O N Although the hands and knees posture for 10 minutes appears to be effective for short-term correction of position of the presenting part of the fetus before labour, advice to use the hands and knees posture for 10 minutes twice daily in the last weeks of pregnancy had no measurable effect on substantive pregnancy outcomes. The potential of the trial of Kariminia 2004 to show effects may be limited by the enrolment of all women (not only women with A C K N O W L E D G E M E N T S Sonja Henderson and Denise Atherton for administrative assistance; Lynn Hampson for literature search. As part of the pre-publication editorial process, this review has been commented on by three peers (an editor and two referees who are external to the editorial team), one or more members of the Pregnancy and Childbirth Group s international panel of consumers and the Group s Statistical Adviser. 4

R E F E R E N C E S References to studies included in this review Andrews 1983 {published data only} Andrews CM, Andrews EC. Nursing, maternal postures, and fetal position. Nursing Research 1983;32:336 41. Kariminia 2004 {published data only} Karaminia A, Keogh J, Chamberlain M. The effect of hands and knees exercise on the incidence of OP position at birth. Perinatal Society of Australia and New Zealand 7th Annual Congress; 2003 March 9-12; Tasmania, Australia. 2003. Kariminia A, Chamberlain ME, Keogh J, Shea A. Randomised controlled trial of effect of hands and knees posturing on incidence of occiput posterior position at birth. BMJ 2004;328:490. Stremler 2005 {published data only} Stremler R. The labour position trial: a randomized, controlled trial of hands and knees positioning for women labouring with a fetus in the occipitoposterior position [thesis]. Toronto: University of Toronto, 2003. Stremler R, Hodnett E, Petryshen P, Stevens B, Weston J, Willan AR. Randomized controlled trial of hands-andknees positioning for occipitoposterior position in labor. Birth 2005;32(4):243 51. References to studies excluded from this review Andrews 1981 {published data only} Andrews CM. Nursing intervention to change a malpositioned fetus. Advances in Nursing Science 1981;3: 53 66. Ou 1997 {published data only} Ou X, Chen X, Su J. Correction of occipito-posterior position by maternal posture during the process of labor. Zhonghua fu chan ke za zhi [Chinese Journal of Obstetrics and Gynecology] 1997;32(6):329 32. Wu 2001 {published data only} Wu X, Fan L, Wang Q. Correction of occipito-posterior by maternal postures during the process of labour. Chung-Hua Fu Chan Ko Tsa Chih 2001;36:468 9. References to studies awaiting assessment Anonymous 1999 {published data only} Anonymous. Hands/knees posture in late pregnancy or labour for malposition (lateral or posterior) of the presenting part. Practising Midwife 1999;2:10 1. Lu 2001 {published data only} Lu JX, Li HX, Shu BL. Clinical observation of lateralprostrate position preventing persistent OP/OT position. Journal of Nursing Science 2001;16(3):136 7. Mao 1996 {published data only} Mao Y, Shan JZ. A study on comprehensive prophylactic intervening in the delivery of persistent occipito-posterior position. Current Advances in Obstetrics and Gynecology 1996;5:126 9. Additional references Andrews 2004 Andrews CM, Andrews EC. Physical theory as a basis for successful rotation of fetal malpositions and conversion of fetal malpresentations. Biological Research for Nursing 2004; 6:126 40. Higgins 2006 Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions 4.2.6 [updated September 2006]. In: The Cochrane Library, Issue 4, 2006. Chichester, UK: John Wiley & Sons, Ltd. RevMan 2003 The Cochrane Collaboration. Review Manager (RevMan). 4.2 for Windows. Oxford, England: The Cochrane Collaboration, 2003. References to other published versions of this review CDSR 1998 Hofmeyr GJ, Kulier R. Hands/knees posture in late pregnancy or labour for fetal malposition (lateral or posterior). Cochrane Database of Systematic Reviews 1998, Issue 2. CDSR 2005 Hofmeyr GJ, Kulier R. Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior). Cochrane Database of Systematic Reviews 2005, Issue 2. [Art. No.: CD001063. DOI: 10.1002/ 14651858.CD001063.pub2] Hofmeyr 1995 Hofmeyr GJ. Hands/knees posture in pregnancy for malposition of presenting part. [revised 04 October 1993]. In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C (eds.) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database [database on disk and CDROM]. The Cochrane Collaboration; Issue 2, Oxford: Update Software; 1995. Indicates the major publication for the study 5

C H A R A C T E R I S T I C S O F S T U D I E S Characteristics of included studies [ordered by study ID] Andrews 1983 Methods Participants The method of random assignment is not specified. In other respects the study is methodologically sound Inclusion criteria: normal pregnancy; 38 or more weeks gestation; fetus in the occipito-posterior or occipito-transverse position (as identified on examination); not in labour; membranes intact; woman in good health Exclusion criteria: previous uterine surgery; conditions associated with, or evidence of polyhydramnios; multiple pregnancy; transverse lie Interventions Hands and knees posture for 10 minutes with lower back arched (n = 20); with pelvic rocking (n = 20) ; with lower back arched and abdominal stroking (n = 20); with pelvic rocking and abdominal stroking; versus control sitting posture (n = 20) After assessment of position, a second positioning was performed, using one of the above 5 postures if no rotation had occurred, or the Sim s position if it had. Only the results of the first posturing are included in this review Outcomes Notes Fetal position after positioning for 10 minutes, assessed by palpation Cleveland, Ohio, USA. Using palpation alone to determine outcome is subject to error, but as the evaluation was made blind to the group allocation, outcome assessment was probably unbiased Risk of bias Item Authors judgement Description Allocation concealment? No C - Inadequate Kariminia 2004 Methods Participants Interventions Outcomes Notes Telephone randomisation in permutated blocks of four. Women with single pregnancy at 36 to 37 weeks; not booked for elective caesarean section Instructions to use hands and knees position with slow pelvic rocking for 10 minutes twice daily from the 37th week until labour; versus daily walking Occiput posterior position at birth (OP delivery, manual or instrumental rotation or OP position at caesarean section; induction of labour; use of epidural analgesia; mode of delivery; duration of labour; episiotomy; Apgar score New South Wales, Australia, 1999 to 2001. Withdrawals 246 in study and 46 in control group; analysis by intention to treat. No loss to follow up. No explanation for imbalance in randomisation (1255 vs 1292) 6

Kariminia 2004 (Continued) Risk of bias Item Authors judgement Description Allocation concealment? Yes A - Adequate Stremler 2005 Methods Participants Included prognostic stratification for parity and anaesthesia used, incorporated random block size 4-6 and centrally controlled with the use of telephone-based computer randomisation system. This study is methologically sound. Women labouring with baby 37 weeks confirmed by ultrasound to be in occipito-posterior position Interventions Experimental group: maintain hands and knees position for as much time as possible over period of 60 mins, with a minimum time of 30 mins. Encouraged to maintain this position after the hour until delivery. Control group: encouraged to use any position other than hands and knees position or any postion that suspended the abdomen Outcomes Notes Clinicians determined baby s head rotation by ultrasound. They were informed about the study definitions of occipito-anterior, occipito-posterior, and occipito-transverse positions by means of written materials, also demonstrated their ultrasound assessment skills during site visits by the principal investigator. Secondary oucome: reduction in persistent back pain. 28 Month period in 2000-2003, 13 university- affiliated hospitals in Argentina, Australia, Canada, England, Israel, and USA. Research ethics board approval. Risk of bias Item Authors judgement Description Allocation concealment? Yes A - Adequate mins: minutes OP: occiput posterior vs: versus 7

Characteristics of excluded studies [ordered by study ID] Study Andrews 1981 Ou 1997 Wu 2001 Reason for exclusion Randomized trial of knee-chest position to change fetal position in women near term. Excluded because all four groups had knee-chest position (plus other manoeuvres). No relevant control group Trial of lateral posture on the same side of the fetal spine to correct occipito-posterior position Trial of lateral posture during labour to correct occipito-posterior position 8

D A T A A N D A N A L Y S E S Comparison 1. Hands and knees posture in pregnancy Outcome or subgroup title No. of studies No. of participants Statistical method Effect size 1 Persistent lateral/posterior fetal 1 100 Risk Ratio (M-H, Fixed, 95% CI) 0.26 [0.18, 0.38] position 2 Posterior position at delivery 1 2547 Risk Ratio (M-H, Fixed, 95% CI) 1.06 [0.85, 1.32] 3 Epidural analgesia 1 2547 Risk Ratio (M-H, Fixed, 95% CI) 1.01 [0.90, 1.14] 4 Caesarean section 1 2547 Risk Ratio (M-H, Fixed, 95% CI) 0.98 [0.80, 1.20] 5 Assisted delivery 1 2547 Risk Ratio (M-H, Fixed, 95% CI) 1.07 [0.88, 1.31] Comparison 2. Hands and knee posture during labour Outcome or subgroup title No. of studies No. of participants Statistical method Effect size 1 Persistent lateral/posterior fetal 1 141 Risk Ratio (M-H, Fixed, 95% CI) 0.90 [0.80, 1.02] position 2 Lateral/posterior position at 1 122 Risk Ratio (M-H, Fixed, 95% CI) 0.76 [0.47, 1.21] delivery 4 Operative delivery 1 147 Risk Ratio (M-H, Fixed, 95% CI) 0.78 [0.46, 1.32] 5 Perineal trauma 1 147 Risk Ratio (M-H, Fixed, 95% CI) 1.02 [0.77, 1.36] 6 Apgar scores< 7 at 1 minute 1 147 Risk Ratio (M-H, Fixed, 95% CI) 0.5 [0.18, 1.37] 7 Apgar scores > 7 at 5 mins 1 147 Risk Ratio (M-H, Fixed, 95% CI) 0.22 [0.01, 4.50] Analysis 1.1. Comparison 1 Hands and knees posture in pregnancy, Outcome 1 Persistent lateral/posterior fetal position. 1 Hands and knees posture in pregnancy 1 Persistent lateral/posterior fetal position Andrews 1983 20/80 20/20 100.0 % 0.26 [ 0.18, 0.38 ] Total (95% CI) 80 20 100.0 % 0.26 [ 0.18, 0.38 ] Total events: 20 (Hands and knees), 20 (Control) Test for overall effect: Z = 6.96 (P < 0.00001) 9

Analysis 1.2. Comparison 1 Hands and knees posture in pregnancy, Outcome 2 Posterior position at delivery. 1 Hands and knees posture in pregnancy 2 Posterior position at delivery Kariminia 2004 149/1292 136/1255 100.0 % 1.06 [ 0.85, 1.32 ] Total (95% CI) 1292 1255 100.0 % 1.06 [ 0.85, 1.32 ] Total events: 149 (Hands and knees), 136 (Control) Test for overall effect: Z = 0.56 (P = 0.58) 10

Analysis 1.3. Comparison 1 Hands and knees posture in pregnancy, Outcome 3 Epidural analgesia. 1 Hands and knees posture in pregnancy 3 Epidural analgesia Kariminia 2004 372/1292 357/1255 100.0 % 1.01 [ 0.90, 1.14 ] Total (95% CI) 1292 1255 100.0 % 1.01 [ 0.90, 1.14 ] Total events: 372 (Hands and knees), 357 (Control) Test for overall effect: Z = 0.19 (P = 0.85) Analysis 1.4. Comparison 1 Hands and knees posture in pregnancy, Outcome 4 Caesarean section. 1 Hands and knees posture in pregnancy 4 Caesarean section Kariminia 2004 165/1292 164/1255 100.0 % 0.98 [ 0.80, 1.20 ] Total (95% CI) 1292 1255 100.0 % 0.98 [ 0.80, 1.20 ] Total events: 165 (Hands and knees), 164 (Control) Test for overall effect: Z = 0.22 (P = 0.82) 11

Analysis 1.5. Comparison 1 Hands and knees posture in pregnancy, Outcome 5 Assisted delivery. 1 Hands and knees posture in pregnancy 5 Assisted delivery Kariminia 2004 178/1292 161/1255 100.0 % 1.07 [ 0.88, 1.31 ] Total (95% CI) 1292 1255 100.0 % 1.07 [ 0.88, 1.31 ] Total events: 178 (Hands and knees), 161 (Control) Test for overall effect: Z = 0.70 (P = 0.48) Analysis 2.1. Comparison 2 Hands and knee posture during labour, Outcome 1 Persistent lateral/posterior fetal position. 2 Hands and knee posture during labour 1 Persistent lateral/posterior fetal position Stremler 2005 57/68 68/73 100.0 % 0.90 [ 0.80, 1.02 ] Total (95% CI) 68 73 100.0 % 0.90 [ 0.80, 1.02 ] Total events: 57 (Hands and knees), 68 (Control) Test for overall effect: Z = 1.70 (P = 0.089) 12

Analysis 2.2. Comparison 2 Hands and knee posture during labour, Outcome 2 Lateral/posterior position at delivery. 2 Hands and knee posture during labour 2 Lateral/posterior position at delivery Study or subgroup hands and knees Control Risk Ratio Weight Risk Ratio Stremler 2005 19/60 26/62 100.0 % 0.76 [ 0.47, 1.21 ] Total (95% CI) 60 62 100.0 % 0.76 [ 0.47, 1.21 ] Total events: 19 (hands and knees), 26 (Control) Test for overall effect: Z = 1.16 (P = 0.24) Analysis 2.4. Comparison 2 Hands and knee posture during labour, Outcome 4 Operative delivery. 2 Hands and knee posture during labour 4 Operative delivery Stremler 2005 17/70 24/77 100.0 % 0.78 [ 0.46, 1.32 ] Total (95% CI) 70 77 100.0 % 0.78 [ 0.46, 1.32 ] Total events: 17 (Hands and knees), 24 (Control) Test for overall effect: Z = 0.92 (P = 0.36) 13

Analysis 2.5. Comparison 2 Hands and knee posture during labour, Outcome 5 Perineal trauma. 2 Hands and knee posture during labour 5 Perineal trauma Stremler 2005 40/70 43/77 100.0 % 1.02 [ 0.77, 1.36 ] Total (95% CI) 70 77 100.0 % 1.02 [ 0.77, 1.36 ] Total events: 40 (Hands and knees), 43 (Control) Test for overall effect: Z = 0.16 (P = 0.87) Analysis 2.6. Comparison 2 Hands and knee posture during labour, Outcome 6 Apgar scores< 7 at 1 minute. 2 Hands and knee posture during labour 6 Apgar scores< 7 at 1 minute Stremler 2005 5/70 11/77 100.0 % 0.50 [ 0.18, 1.37 ] Total (95% CI) 70 77 100.0 % 0.50 [ 0.18, 1.37 ] Total events: 5 (Hands and knees), 11 (Control) Test for overall effect: Z = 1.35 (P = 0.18) 14

Analysis 2.7. Comparison 2 Hands and knee posture during labour, Outcome 7 Apgar scores > 7 at 5 mins. 2 Hands and knee posture during labour 7 Apgar scores > 7 at 5 mins Stremler 2005 0/70 2/77 100.0 % 0.22 [ 0.01, 4.50 ] Total (95% CI) 70 77 100.0 % 0.22 [ 0.01, 4.50 ] Total events: 0 (Hands and knees), 2 (Control) Test for overall effect: Z = 0.98 (P = 0.33) W H A T S N E W Last assessed as up-to-date: 29 July 2007. Date Event Description 3 September 2008 Amended Converted to new review format. H I S T O R Y Protocol first published: Issue 2, 1998 Review first published: Issue 2, 1998 Date Event Description 30 July 2007 New citation required and conclusions have changed With the inclusion of the Stremler 2005 data, there is evidence that the use of the hands and knees posture during labour relieves back pain 2 July 2007 New search has been performed Search updated. One new trial included (Stremler 2005). Two further trials identified and added to awaiting assessment while the full papers are obtained (Lu 2001; Mao 1996). 15

(Continued) 18 November 2004 New search has been performed Search updated. Data from recent large trial added (Kariminia 2004). The Kariminia trial is a large trial (about 2500 women), and clearly shows that advice to assume the knees and chest posture for 10 minutes, 3 times daily in late pregnancy, does not alter pregnancy outcomes. It is the first trial reviewed which provides information on the effects of this posture on pregnancy outcomes C O N T R I B U T I O N S O F A U T H O R S Justus Hofmeyr prepared the original version of the review. Regina Kulier quality checked and did the first revision of the review. Sandra Hunter undertook major revision of the review in 2007. D E C L A R A T I O N S O F None known. I N T E R E S T S O U R C E S O F S U P P O R T Internal sources (GJH) Effective Care Research Unit, University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of Health, South Africa. Department of Obstetrics and Gynaecology, Geneva University Hospital, Switzerland. External sources (GJH) South African Medical Research Council, South Africa. I N D E X T E R M S Medical Subject Headings (MeSH) Labor Presentation; Posture; Delivery, Obstetric [ methods]; Pregnancy Outcome; Version, Fetal 16

MeSH check words Female; Humans; Pregnancy 17