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., Bernadette de Gasquet M.D., Stéphane Turcotte M.Sc., Nancy Girard M.D., Mélodie Bourdages, Maryse Houde, Sylvie Dodin M.D.-M.Sc. Université Laval, Québec, Canada INTRODUCTION Several initiatives aim to reintroduce a certain freedom in positioning at delivery. Dr Bernadette de Gasquet is a French physician who developed the APOR B method offering a variety of positions for labor and delivery. She was inspired by the positions spontaneously adopted by women who deliver without analgesia as well as labor and articular physiology. The positions include a lateral, hand/knee, squat, ventral and modified dorsal position. APOR B method also proposes an alternative 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 better opening and mobility of the pelvis and a less traumatic and more “physiologic” delivery. In a RCT1, lateral decubitus of APOR B method was associated with an increased proportion 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 position, lack of blinding and exclusions after randomization). 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. Table 2. Mode of delivery (N=276) ABSTRACT Objective: The objective of this study was to compare alternative positions with the classic supine position at delivery. Study design: We undertook a comparative, retrospective investigation of 276 singleton deliveries at ≥36 weeks. Alternative birthing positions used by 2 general practitioners (GPs) were compared to the classic supine position used by 2 other GPs with similar years of experience. We assessed obstetric outcomes with logistic regression analyses. Results: The study populations were similar except for more cases of induced labor (40% vs 27%, p=0.0303) and earlier gestational age at delivery (39.1±1.4 vs 39.4±1.0 weeks of amenorrhea, p=0.032) in the alternative birthing positions 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 alternative and classical birthing positions, respectively. 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 proportion of umbilical cord arterial pH under 7.20 was increased in the alternative birthing positions group (32% vs 20%, aOR=2.0, aCI=1.1-3.8). Conclusion: The outcomes of both methods of positioning 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 interventions while implanting alternative positions. Given the growing interest in alternative positions, our research highlights the importance of conducting further prospective studies on the subject. Variable n (%) APOR B method N=95 Classic position N=181 OR 95% CI ORa 95% CIa SVD 70 (73.7) 131 (72.4) 1.07 0.61-1.87 1.02 0.57-1.84 AVD vacuum forceps 17 (17.9) 0 (0.0) 40 (22.1) 33 (18.2) 7 (3.9) 0.77 0.98 0.19 0.41-1.44 0.51-1.87 0.00-1.30 0.84 1.09 0.18 0.44-1.60 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 Table 7. Third-stage complications (N=258)a Variable n (%) APOR B method N=87 Classic position N=171 OR 95% CI ORa 95% CIa PPH 8 (9.2) 9 (5.3) 1.82 0.68-4.90 2.02 0.74-5.56 ↓hb ≥ 30 g/L 8 (9.3) 14 (8.3) 1.13 0.45-2.80 1.20 0.47-3.02 Manual placenta removal 7 (8.0) 6 (3.5) 2.41 0.78-7.39 2.49 0.80-7.81 Table 3. Perineal outcomes (N=258)b Variable n (%) APOR B method N=87 Classic position N=171 OR 95% CI ORa 95% CIa No tearing 17 (19.5) 33 (19.5) 1.00 0.52-1.92 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) 1.39 0.77-2.50 1.38 0.76-2.51 Episiotomy 11 (12.6) 16 (9.4) 1.40 0.62-3.17 1.54 0.67-3.55 Episiotomy w/o extension 9 (10.3) 11 (6.5) 1.66 0.66-4.17 2.11 0.82-5.47 Severe 3rd degree 4th degree 5 (5.7) 0 (0.0) 8 (4.7) 6 (3.6) 2 (1.2) 1.23 0.87 0.39-3.87 0.49-5.59 0.00-10.36 1.10 1.53 0.76 0.34-3.57 0.44-5.30 0.00-9.75 Periurethral 19 (21.8) 29 (17.2) 1.35 0.71-2.58 1.37 0.71-2.66 Vaginal 13 (14.9) 48 (28.4) 0.44 0.23-0.87 0.45 0.23-0.89 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 alternative positions and a possible delay in instrumentation 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 statistically significant with consideration 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 identified no significant threat to the newborns2. In contrast with the RCT of Brément et al.1, we found no statistically significant difference in the proportion of intact perineums. Finally, the difference regarding vaginal tears has little clinical significance. Flaws: possible selection and information bais due to the retrospective design, limited power for some issues, groups not comparable in terms of induction of labor and gestiational age but adjusment was provided and did not change our results. OBJECTIVE To compare APOR B method to the classic dorsal position in regards to obstetric outcomes. METHOD Retrospective comparative 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 position group: all deliveries from 04-2007 to 02-2010 performed by 2 physicians, similar for age, number of years in practice and number of deliveries per year, who use the classical dorsal position. Inclusion: living birth ≥ 36 weeks of gestation. Exclusion: multiple gestation, elective or planned cesareans (ex: malpresentation, uterine scar, etc.), VBAC and severe preeclampsia. Identification of subjects : departmental registry and coded electronic archives. Data collection from medical records. Statistical analysis were undertaken with SAS 9.2. Baseline characteristics 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 multivariate logistic regression. Table 4. Labor duration (N=258)b Variable min ± SD APOR B method N=87 Classic position N=171 p pa Stage 1 355  211 383  214 0.3174 0.8028 Stage 2 68  70 55  59 0.1057 0.0616 Stage 3 10  11 15  61 0.5116 0.5165 Total 434  246 453  257 0.5678 0.8958 RÉSUMÉ Objectif: Comparer les issues obstétricales d’une méthode alternative de positionnement à l’accouchement à la position classique en décubitus dorsal. Méthode: Nous avons étudié rétrospectivement 276 accouchements effectués entre 2007 et 2010 par 4 omnipraticiens, 2 utilisant une méthode alternative de positionnement (méthode APOR B de Gasquet) et 2 autres utilisant 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 complications du 3e stade au moyen d’analyses de régression logistique. 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 identifié une plus grande proportion de travail induit (40% vs 27%, p=0.0303) et un âge gestationnel plus précoce (39.1±1.4 vs 39.4±1.0 semaines d’aménorrhée, p=0.032) dans le groupe des positions alternatives (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 positions alternatives et classique respectivement. 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 rétention placentaire. Cependant, il y avait une plus grande proportion de pH de l’artère ombilicale < 7.20 dans le groupe des positions alternatives (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 réalisation d’interventions d’urgence dans les positions alternatives d’accouchement. Vu l’intérêt croissant pour les positions alternatives, notre étude souligne l’importance de mener des études prospectives sur le sujet.   Table 8. Post-hoc analyses comparing arterial cord pH (N=276) Variable n (%) APOR B method N=95 Classic position N=181 OR 95% CI ORa 95% CIa pHa < 7.20 27 (31.8) 30 (19.5) 1.92 1.05-3.53 2.048 1.10-3.81 pHa < 7.15 11 (12.9) 11 (7.1) 1.93 0.80-4.67 2.070 0.84-5.09 pHa < 7.10 3 (3.5) 4 (2.6) 1.37 0.30-6.28 1.145 0.24-5.51 Table 5. Labor progression (N=276) Variable n (%) APOR B method N=95 Classic Position N=181 OR 95% CI ORa 95% CIa Oxytocin 59 (63.4) 129 (71.3) 0.70 0.41-1.19 0.76 0.43-1.33 ARM 54 (58.1) 89 (49.2) 1.43 0.86-2.37 1.62 0.95-2.75 Epidural 62 (66.0) 125 (69.1) 0.87 0.51-1.48 1.02 0.58-1.80 Interventiond for dystocia stage 1 stage 2 8 (33.3) 1(1.0) 7 (7.4) 18 (36.7) 3 (1.7) 15 (8.6) 0.83 0.63 0.88 0.35-1.99 0.07-6.15 0.35-2.24 0.74 0.44 0.84 0.29-1.86 0.04-4.39 0.32-2.21 Shoulder dystocia 4 (4.6) 9 (5.3) 0.26-2.90 1.00 0.29-3.41 Table 1. Descriptive characteristics (N=276) Variable APOR B method N=95 Classic position N=181 p Age at delivery, yrs ± SD 29.8  4.7 28.9  4.7 0.1250 Tobacco during pregnancy, n (%) 15 (15.8) 35 (19.3) 0.4672 Alcohol during pregnancy, n (%) 5 (5.3) 13 (7.2) 0.5395 Drug during pregnancy, n (%) 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) Employed (vs non-employed), n (%) 79 (85.9) 148 (83.1) 0.5622 BMI, m ± SD at first pregnancy visit at last pregnancy visit 24.1 ± 4.7 29.2 ± 4.9 24.0 ± 5.3 29.7 ± 5.5 0.9363 0.4628 Parity, n (%) nulliparity 1 2 3+ 47 (50.5) 32 (34.4) 13 (14.0) 1 (1.1) 87 (48.9) 64 (36.0) 22 (12.4) 5 (2.8) 0.9519 Weeks of gestation, m ± SD 39.1  1.4 39.4  1.0 0.0321 Pregnancy complicationsa, n (%) 7 (7.4) 7 (3.9) 0.2506 Induction of labor, n (%) 38 (40.0) 49 (27.2) 0.0303 Female newborn, n (%) 46 (48.4) 94 (51.9) 0.5792 Weight of newborn, m ± SD 3475  508 3476  430 0.9814 CONCLUSION Birthing positions should be studied in further randomized controlled trial, especially to clarify concerns about lower umbilical cord arterial pH. The mean time to accomplish emergency interventions from alternative birthing positions should be assessed. Strategies to improve delay in intervention could then be developed if needed. Table 6. Fetal well-being (N=276) REFERENCES Brément S, Mossan S, Belery A, Racinet C. Gynecol Obstet Fertil 2007;35(7-8):637-44. Gilstrap L, Leveno K, Burris J, Williams M, Little B. Am J Obstet Gynecol 1989;161(3):825-30. Variable n (%) APOR B method N=95 Classic position N=181 OR 95% CI ORa 95% CIa Abnormal F♡ 33 (34.7) 60 (33.1) 1.07 0.64-1.81 1.20 0.70-2.07 Meconium AF 16 (17.2) 30 (16.9) 1.02 0.52-1.98 0.60-2.38 Nuchal cord 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) 5 (2.8) 0.28 0.00-2.10 0.35 0.00-2.65 Arterial pH < 7.20 27 (31.8) 30 (19.5) 1.92 1.05-3.53 2.05 1.10-3.81 Interventiond for abnormal F♡ stage 1 stage 2 15 (15.8) 3 (3.2) 12 (12.6) 30 (16.6) 2 (1.1) 28 (15.5) 0.94 2.92 0.79 0.48-1.86 0.48-17.78 0.38-1.64 1.08 2.51 0.93 0.54-2.16 0.40-15.94 0.44-1.96 Resuscitatione 7 (7.4) 8 (4.4) 1.72 0.60-4.90 1.60 0.55-4.67 Adjustment LEGEND a. GDM (1;3), polyhydramnios (2;1), MPE and GHT (1;2), oligohydramnios (1;0), abruptio placenta (1;1) and IUGR (1;0). (APOR B, classic) b. Cesareans were excluded c. No consideration of periurethral or vaginal tears d. Ceserean, forceps or vacuum e. ≥ Positive pressure ventilation Lateral decubitus of APOR B method