Maternal positioning with flexed thighs to correct foetal occipito-posterior position in labour: A systematic review and meta-analysis.

BACKGROUND: Foetal occipto-posterior position during labour can contribute to negative outcomes. Encouraging women to adopt positions utilising thigh flexion with the aim of increasing pelvic diameters and promoting foetal rotation to the occpito-anterior position are often used. However, the efficacy of these strategies has not yet been determined. OBJECTIVE: To compare the effects of maternal hands and knees or lateral positions with flexed thighs versus control in rotating foetal occipito-posterior to occipito-anterior in the first stage of labour. METHODS: The databases such as MEDLINE/PubMed, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL) and Embase were searched with dates ranging from 1947 to 2019. We included randomised controlled trials (RCTs) that compared maternal hands and knees, and lateral positions incorporating flexed thighs (spine-femur angle of ≥ 90°) versus control to rotate foetal malposition in the first stage of labour and published in English. Methodological quality was assessed based on Cochrane's Risk of Bias 2 for randomized controlled trials. Two teams of researchers completed the study selection, quality assessment, data extraction and meta-analysis. RESULTS: Seven RCTs met our inclusion criteria (n = 1422). Whilst there was an increase in the rate of spontaneous foetal rotation from the occipito-posterior to the anterior position, particularly in the first hour after the intervention was adopted, this did not reach statistical significance (RR, 1.15; 95% CI, 0.96-1.39, p = 0.13). The effect was insufficient to influence rates of spontaneous vaginal birth (RR, 1.04; 95% CI, 0.85-1.26, p = 0.72) whilst there was a reduction in the duration of first stage labour (Mean-difference, -27.34; 95% CI, -45.96, -8.72, p = 0.004). CONCLUSION: This systematic review reports no significant correlation between maternal positioning with flexed thighs and foetal rotation from occipito-posterior to occipito-anterior position during first stage labour. The specific maternal positions tested did not impact on the majority of other labour and birth outcomes. Given that the majority of fetuses will rotate spontaneously to an occipito-anterior position it may be that maternal posturing facilitates earlier rotation in this group but has no effect on the subset of infants that would otherwise persist in the occipito-posterior position to birth.