ALTERNATIVE BIRTHING POSITIONS COMPARED TO THE SUPINE POSITION: A RETROSPECTIVE STUDY OF OBSTETRICS OUTCOMES COMPARAISON D'UNE MÉTHODE ALTERNATIVE DE POSITIONNEMENT À L'ACCOUCHEMENT À LA POSITION CLASSIQUE EN DÉCUBITUS DORSAL Sarah Maheux-‐Lacroix M.D.-‐M.Sc., Myriam Tremblay M.D., Nadine Dubois M.D., Bernadede de Gasquet M.D., Stéphane Turcode M.Sc., Nancy Girard M.D., Mélodie Bourdages, Maryse Houde, Sylvie Dodin M.D.-‐M.Sc. Université Laval, Québec, Canada ABSTRACT Objec;ve: The objecVve of this study was to compare alternaVve posiVons with the classic supine posiVon at delivery. Study design: We undertook a comparaVve, retrospecVve invesVgaVon of 276 singleton deliveries at ≥36 weeks. AlternaVve birthing posiVons used by 2 general pracVVoners (GPs) were compared to the classic supine posiVon used by 2 other GPs with similar years of experience. We assessed obstetric outcomes with logisVc regression analyses. Results: The study populaVons were similar except for more cases of induced labor (40% vs 27%, p=0.0303) and earlier gestaVonal age at delivery (39.1±1.4 vs 39.4±1.0 weeks of amenorrhea, p=0.032) in the alternaVve birthing posiVons group (adjustment provided). Mode of delivery and perineal outcomes were similar, with 74% and 72% (p=0.8164) of spontaneous vaginal deliveries and 38% and 44% (p=0.3682) of intact perineums for alternaVve and classical birthing posiVons, respecVvely. No diﬀerences were observed in the frequency of abnormal fetal heart rate, Apgar score <7 at 5 minutes, labor or shoulder dystocia, blood loss and retained placenta. However, the proporVon of umbilical cord arterial pH under 7.20 was increased in the alternaVve birthing posiVons group (32% vs 20%, aOR=2.0, aCI=1.1-‐3.8). Conclusion: The outcomes of both methods of posiVoning at delivery were mostly equivalent. Lower umbilical cord arterial pH in APOR B group may have resulted from the challenge of fetal heart monitoring and quick emergency intervenVons while implanVng alternaVve posiVons. Given the growing interest in alternaVve posiVons, our research highlights the importance of conducVng further prospecVve studies on the subject. RÉSUMÉ Objec;f: Comparer les issues obstétricales d’une méthode alternaVve de posiVonnement à l’accouchement à la posiVon classique en décubitus dorsal. Méthode: Nous avons étudié rétrospecVvement 276 accouchements eﬀectués entre 2007 et 2010 par 4 omnipraVciens, 2 uVlisant une méthode alternaVve de posiVonnement (méthode APOR B de Gasquet) et 2 autres uVlisant la méthode classique en décubitus dorsal. Nous avons comparé le mode d’accouchement, le type de déchirures, la durée du travail, la dystocie, le bien-‐être fœtal et les complicaVons du 3e stade au moyen d’analyses de régression logisVque. Résultats: Les deux groupes étaient similaires en ce qui a trait à l’âge, la parité, l’ethnie, l’indice de masse corporelle, les habitus, le statut marital et socio-‐économique ainsi que le poids et le sexe des nouveau-‐nés. Nous avons idenVﬁé une plus grande proporVon de travail induit (40% vs 27%, p=0.0303) et un âge gestaVonnel plus précoce (39.1±1.4 vs 39.4±1.0 semaines d’aménorrhée, p=0.032) dans le groupe des posiVons alternaVves (ajustement eﬀectué). Le mode d’accouchement et les issues périnéaux étaient similaires pour les deux groupes avec 74% et 72% (p=0.8164) d’accouchements vaginaux spontanés et 38% et 44% (p=0.3682) de périnées intacts pour les posiVons alternaVves et classique respecVvement. Aucune diﬀérence n’a été observée concernant les anomalies du cœur foetal, le score d’Apgar <7 à 5 minutes, la dystocie du travail et des épaules, les pertes sanguines et la rétenVon placentaire. Cependant, il y avait une plus grande proporVon de pH de l’artère ombilicale < 7.20 dans le groupe des posiVons alternaVves (32% vs 20%, RCa=2.0, ICa=1.1-‐3.8). Conclusion: Les deux méthodes étaient équivalentes pour la plupart des issues. Les pH de l’artère ombilicale plus bas dans le groupe APOR B pourraient découler du déﬁ que représentent le monitoring foetal et la réalisaVon d’intervenVons d’urgence dans les posiVons alternaVves d’accouchement. Vu l’intérêt croissant pour les posiVons alternaVves, notre étude souligne l’importance de mener des études prospecVves sur le sujet. Table 2. Mode of delivery (N=276) INTRODUCTION •  Several iniVaVves aim to reintroduce a certain freedom in posiVoning at delivery. •  Dr Bernadede de Gasquet is a French physician who developed the APOR B method oﬀering a variety of posiVons for labor and delivery. She was inspired by the posiVons spontaneously adopted by women who deliver without analgesia as well as labor and arVcular physiology. The posiVons include a lateral, hand/knee, squat, ventral and modiﬁed dorsal posiVon. APOR B method also proposes an alternaVve technique for expulsive eﬀorts (back straight and stretched, transverse abdominal muscles contracted, exhalatory pushing, etc.) •  Based on anatomophysiological arguments, APOR B method could allow a beder opening and mobility of the pelvis and a less traumaVc and more “physiologic” delivery. In a RCT1, lateral decubitus of APOR B method was associated with an increased proporVon of intact perineums (57% vs 48%, p=0,032). However, this study had several ﬂaws that could have biased the results (more episiotomies in classic posiVon, lack of blinding and exclusions aver randomizaVon). •  Despite the lack of evidence, more and more physicians and midwives from France, Belgium, Switzerland, Spain, Portugal, Luxembourg, Japan, Israel, Morocco, and Canada are trained in the APOR B method. OBJECTIVE •  To compare APOR B method to the classic dorsal posiVon in regards to obstetric outcomes. METHOD •  RetrospecVve comparaVve study. •  APOR B group: all deliveries from 04-‐2008 to 02-‐2010 performed by 2 physicians who started to use APOR B method in April 2008. •  Classic posiVon group: all deliveries from 04-‐2007 to 02-‐2010 performed by 2 physicians, similar for age, number of years in pracVce and number of deliveries per year, who use the classical dorsal posiVon. •  Inclusion: living birth ≥ 36 weeks of gestaVon. •  Exclusion: mulVple gestaVon, elecVve or planned cesareans (ex: malpresentaVon, uterine scar, etc.), VBAC and severe preeclampsia. •  IdenVﬁcaVon of subjects : departmental registry and coded electronic archives. •  Data collecVon from medical records. •  StaVsVcal analysis were undertaken with SAS 9.2. Baseline characterisVcs were compared (Student t test, Chi-‐squared and exact Fisher test) and retained for adjustment if they diﬀered signiﬁcantly (p<0.05). Crude and adjusted OR and 95% CI were calculated using uni and mulVvariate logisVc regression. Age at delivery, yrs ± SD Tobacco during pregnancy, n (%) APOR B method N=95 29.8 ± 4.7 15 (15.8) Classic posi;on N=181 28.9 ± 4.7 35 (19.3) 0.1250 0.4672 Alcohol during pregnancy, n (%) 5 (5.3) 13 (7.2) 0.5395 Drug during pregnancy, n (%) p 0 (0.0) 3 (1.7) 0.5535 White (vs non-‐white), n (%) 92 (96.8) 175 (96.7) 1.0000 Partnered/married (vs single/divorced), n (%) 94 (98.9) 178 (98.3) 1.0000 Employed (vs non-‐employed), n (%) BMI, m ± SD 79 (85.9) 148 (83.1) 0.5622 24.1 ± 4.7 29.2 ± 4.9 24.0 ± 5.3 29.7 ± 5.5 0.9363 0.4628 at ﬁrst pregnancy visit at last pregnancy visit Parity, n (%) 0.9519 47 (50.5) 32 (34.4) 13 (14.0) 1 (1.1) 87 (48.9) 64 (36.0) 22 (12.4) 5 (2.8) Weeks of gestaVon, m ± SD 39.1 ± 1.4 39.4 ± 1.0 0.0321 Pregnancy complicaVonsa, n (%) InducVon of labor, n (%) 7 (7.4) 38 (40.0) 7 (3.9) 49 (27.2) 0.2506 0.0303 46 (48.4) 94 (51.9) 0.5792 3475 ± 508 3476 ± 430 0.9814 nulliparity 1 2 3+ Female newborn, n (%) Weight of newborn, m ± SD Classic posi;on N=181 131 (72.4) OR 95% CI ORa 95% CIa 1.07 0.61-‐1.87 1.02 0.57-‐1.84 17 (17.9) 40 (22.1) 0.77 0.41-‐1.44 0.84 0.44-‐1.60 forceps 17 (17.9) 0 (0.0) 33 (18.2) 7 (3.9) 0.98 0.19 0.51-‐1.87 0.00-‐1.30 1.09 0.18 0.56-‐2.13 0.00-‐1.26 Emergency C/S 8 (8.4) 10 (5.5) 1.57 0.60-‐4.13 1.42 0.51-‐3.94 SVD AVD vacuum Adjustment Table 7. Third-‐stage complicaVons (N=258)a Variable n (%) PPH ↓hb ≥ 30 g/L Manual placenta removal APOR B method N=87 8 (9.2) 8 (9.3) Classic posi;on N=171 9 (5.3) 14 (8.3) 1.82 1.13 0.68-‐4.90 2.02 0.45-‐2.80 1.20 0.74-‐5.56 0.47-‐3.02 7 (8.0) 6 (3.5) 2.41 0.78-‐7.39 2.49 0.80-‐7.81 OR 95% CI ORa 95% CIa Table 3. Perineal outcomes (N=258)b Classic posi;on N=171 33 (19.5) OR 95% CI ORa 95% CIa No tearing APOR B method N=87 17 (19.5) 1.00 0.52-‐1.92 1.00 0.51-‐1.95 Intact perineumc 33 (37.9) 74 (43.8) 0.79 0.46-‐1.33 0.78 0.45-‐1.34 1st degree 14 (16.1) 38 (22.5) 0.66 0.34-‐1.30 0.60 0.30-‐1.20 2nd degree 25 (28.7) 38 (22.5) 1.39 0.77-‐2.50 1.38 0.76-‐2.51 Episiotomy Episiotomy w/o extension Severe 11 (12.6) 16 (9.4) 1.40 0.62-‐3.17 1.54 0.67-‐3.55 9 (10.3) 11 (6.5) 1.66 0.66-‐4.17 2.11 0.82-‐5.47 5 (5.7) 8 (4.7) 1.23 0.39-‐3.87 1.10 0.34-‐3.57 Periurethral Vaginal 19 (21.8) 13 (14.9) 29 (17.2) 48 (28.4) 1.35 0.44 0.71-‐2.58 0.23-‐0.87 1.37 0.45 0.71-‐2.66 0.23-‐0.89 Variable n (%) 3rd degree 4th degree 5 (5.7) 0 (0.0) 6 (3.6) 2 (1.2) 1.66 0.87 0.49-‐5.59 0.00-‐10.36 1.53 0.76 0.44-‐5.30 0.00-‐9.75 Table 4. Labor duraVon (N=258)b Variable min ± SD Stage 1 Stage 2 Stage 3 Total APOR B method N=87 Classic posi;on N=171 p pa 355 ± 211 383 ± 214 0.3174 0.8028 55 ± 59 0.1057 0.0616 10 ± 11 15 ± 61 0.5116 0.5165 434 ± 246 68 ± 70 453 ± 257 0.5678 0.8958 Variable n (%) Classic Posi;on N=181 129 (71.3) 89 (49.2) OR 95% CI ORa 95% CIa Oxytocin ARM APOR B method N=95 59 (63.4) 54 (58.1) 0.70 1.43 0.41-‐1.19 0.86-‐2.37 0.76 1.62 0.43-‐1.33 0.95-‐2.75 Epidural 62 (66.0) 125 (69.1) 0.87 0.51-‐1.48 1.02 0.58-‐1.80 IntervenVond for dystocia 8 (33.3) 18 (36.7) 0.83 0.35-‐1.99 0.74 0.29-‐1.86 4 (4.6) 9 (5.3) 0.87 0.26-‐2.90 1.00 0.29-‐3.41 stage 1 stage 2 Shoulder dystocia 1(1.0) 7 (7.4) 3 (1.7) 15 (8.6) 0.63 0.88 0.07-‐6.15 0.35-‐2.24 0.44 0.84 0.04-‐4.39 0.32-‐2.21 APOR B method N=95 33 (34.7) Classic 95% CI posi;on OR N=181 60 (33.1) 1.07 0.64-‐1.81 ORa 95% CIa 1.20 0.70-‐2.07 Meconium AF Nuchal cord 16 (17.2) 30 (16.9) 1.02 0.52-‐1.98 1.20 0.60-‐2.38 34 (35.8) 61 (33.7) 1.10 0.65-‐1.85 1.16 0.68-‐1.98 APGAR < 7 at 5m 0 (0.0) 27 (31.8) 5 (2.8) 0.28 0.00-‐2.10 30 (19.5) 1.92 1.05-‐3.53 0.35 2.05 0.00-‐2.65 1.10-‐3.81 IntervenVond for abnormal F♡ 15 (15.8) stage 1 3 (3.2) 30 (16.6) 0.94 0.48-‐1.86 1.08 0.54-‐2.16 1.60 0.55-‐4.67 Abnormal F♡ Arterial pH < 7.20 pHa < 7.20 pHa < 7.15 pHa < 7.10 APOR B method N=95 27 (31.8) Classic posi;on N=181 30 (19.5) OR 95% CI ORa 95% CIa 1.92 1.05-‐3.53 2.048 1.10-‐3.81 11 (12.9) 11 (7.1) 1.93 0.80-‐4.67 2.070 0.84-‐5.09 3 (3.5) 4 (2.6) 1.37 0.30-‐6.28 1.145 0.24-‐5.51 CONCLUSION •  Birthing posiVons should be studied in further randomized controlled trial, especially to clarify concerns about lower umbilical cord arterial pH. •  The mean Vme to accomplish emergency intervenVons from alternaVve birthing posiVons should be assessed. Strategies to improve delay in intervenVon could then be developed if needed. REFERENCES Table 6. Fetal well-‐being (N=276) Variable n (%) DISCUSSION •  Two methods were equivalent for most issues. •  However, umbilical cord arterial pH were lower with APOR B method. This result is consistent with results of Brément et al.1 in which serum lactate in the umbilical cord artery was higher (3.35 vs 3.53 mmol/L ) in APOR B group. Our hypotheses are that lower pH could result from the challenge of fetal monitoring in alternaVve posiVons and a possible delay in instrumentaVon or management of shoulder dystocia when there is a need to change for dorsal decubitus. Post-‐hoc analyses showed that the magnitude of diﬀerences decreased and became not staVsVcally signiﬁcant with consideraVon of 7.15 and 7.10 as threshold (Table 8). Most fetuses will tolerate pH as low as 7.00 without neurological impairment so we idenVﬁed no signiﬁcant threat to the newborns2. •  In contrast with the RCT of Brément et al.1, we found no staVsVcally signiﬁcant diﬀerence in the proporVon of intact perineums. Finally, the diﬀerence regarding vaginal tears has lidle clinical signiﬁcance. •  Flaws: possible selecVon and informaVon bais due to the retrospecVve design, limited power for some issues, groups not comparable in terms of inducVon of labor and gesVaVonal age but adjusment was provided and did not change our results. Table 8. Post-‐hoc analyses comparing arterial cord pH (N=276) Table 5. Labor progression (N=276) Variable n (%) Table 1. DescripVve characterisVcs (N=276) Variable APOR B method N=95 70 (73.7) Variable n (%) stage 2 12 (12.6) 2 (1.1) 28 (15.5) 2.92 0.79 ResuscitaVone 7 (7.4) 8 (4.4) 1.72 0.60-‐4.90 0.48-‐17.78 0.38-‐1.64 2.51 0.93 0.40-‐15.94 0.44-‐1.96 1. Brément S, Mossan S, Belery A, Racinet C. Gynecol Obstet FerVl 2007;35(7-‐8): 637-‐44. 2.  Gilstrap L, Leveno K, Burris J, Williams M, Lidle B. Am J Obstet Gynecol 1989;161 (3):825-‐30. LEGEND a. GDM (1;3), polyhydramnios (2;1), MPE and GHT (1;2), oligohydramnios (1;0), abrupVo placenta (1;1) and IUGR (1;0). (APOR B, classic) b. Cesareans were excluded c. No consideraVon of periurethral or vaginal tears d. Ceserean, forceps or vacuum e. ≥ PosiVve pressure venVlaVon Lateral decubitus of APOR B method