Hands-and-knees posturing and fetal occiput anterior position: a systematic review and meta-analysis

Persistent occiput posterior and occiput transverse positions are associated with adverse maternal and neonatal outcomes. The objective of this study was to assess if the use of hands-and-knees posturing increased the rate of occiput anterior position immediately after posturing during the second stage of labor or at the time of birth.

An electronic search of PubMed, EMBASE, Clinicaltrials.gov, and Cochrane Central Register of Controlled Trials was performed from inception to September 2020.

Eligibility criteria included all randomized controlled trials of singleton gestations at ≥36 weeks' gestation that were randomized to either the hands-and-knees posture group or control group. The primary outcome was a composite of occiput anterior positioning during the second stage of labor or at birth. Individual components of the composite were assessed as secondary outcomes. Additional secondary outcomes were a change to occiput anterior position immediately after the intervention, use of regional anesthesia, duration of labor, mode of delivery, third- or fourth-degree perineal laceration, neonatal birthweight, and Apgar score less than 7 at 5 minutes.

The methodological quality of all the included studies was evaluated using the Cochrane Handbook for Systematic Reviews of Interventions. A meta-analysis was performed using the random effects model of DerSimmonian and Laird to produce a summary of the treatment effects in terms of relative risk or mean difference with 95% confidence intervals.

Of the 1079 studies screened, 5 met the inclusion criteria (n=1727 hands-and-knees posture vs n=1641 controls). When compared with the control group, patients who adopted the hands-and-knees posture had the same rate of occiput anterior positioning in the second stage of labor or at birth (81.2% vs 81.2%; relative risk, 1.03; 95% confidence interval, 0.92-1.14), as well as immediately after the intervention (34.1% vs 18.0%; relative risk, 1.60; 95% confidence interval, 0.88-2.90). On the basis of the post hoc subgroup analysis of patients with an ultrasound-diagnosed malposition before posturing, there was a higher rate of occiput anterior positioning immediately after the intervention (17.0% vs 10.3%; relative risk, 1.63; 95% confidence interval, 1.06-2.52), but this relationship did not persist at delivery. The remainder of the subgroup analyses and secondary outcomes were not significant.

Adopting a hands-and-knees posture does not increase the rate of occiput anterior positioning at time of delivery.