Upright positions in childbirth and the prevention of perineal lacerations: a systematic review and meta-analysis

Rocha, Bruna Dedavid da; Zamberlan, Cláudia; Pivetta, Hedioneia Maria Foletto; Santos, Bianca Zimmermann; Antunes, Bibiana Sales

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REVIEW • Rev. esc. enferm. USP 54 • 2020 • https://doi.org/10.1590/S1980-220X2018027503610 copy

Upright positions in childbirth and the prevention of perineal lacerations: a systematic review and meta-analysis^* * Extracted from the dissertation: “Posições verticalizadas no parto e a prevenção de lacerações perineais: revisão sistemática e metanálise”, Universidade Franciscana, 2017.

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective

To investigate whether the adoption of upright positions by women during childbirth prevents perineal lacerations compared to the lithotomy position.

Method

A systematic review with meta-analysis. The searches were carried out in the databases: LILACS, Medline/PubMed, CINAHL, Cochrane Library, Web of Science, Science Direct and Scopus. Searches in the gray literature were conducted on Google Scholar and OpenGrey databases. Reference lists of included articles were also considered. The Cochrane collaboration tool and ACROBAT-NRSI were used to analyze the methodological quality of the articles.

Results

There were 26 studies listed and 8 were selected for the meta-analysis. The level of scientific evidence was classified by the GRADE System and considered high. There was no statistically significant difference between upright positions in relation to horizontal positions. Despite this finding, the upright positions showed reduced rates of severe perineal lacerations.

Conclusion

Adopting upright positions in normal delivery can be encouraged by professionals as it can prevent severe perineal lacerations; however, it is not possible to accurately affirm their effectiveness to the detriment of horizontal positions for an intact perineum outcome.

Obstretric Nursing; Parturition; Modalities, Position; Lacerations; Review; Meta-Analysis

#1	second stage labor [MeSH Terms*]
#2	posture [MeSH Terms*]
#3	lacerations [MeSH Terms*]
#4	perineum [MeSH Terms*]
#5	segunda fase de trabalho de parto [DeCS^†]
#6	posição [palavra-chave]
#7	períneo [DeCS^†]
#8	lacerações [DeCS^†]
Medline/Pubmed^‡/Scopus^§/Web of Science: #1 AND #2 CINAHL**/Cochrane Library: #1 AND #2 AND #3 (CINAHL titles – research as keywords; Cochrane Library – Title, abtract, keywords) Science Direct: #1 AND #2 AND #4 (all fields) Open Grey: #1 Google Scholar: #1 AND #2 AND #3 AND #4; #5 AND #6 AND #7 AND #8 LILACS**^††: #5 AND #6 Filters: excluded dissertations, theses, reviews and books.

Author	Country/Year	Method	Intervention	Outcome	GRADE
Seratti et al⁽¹⁸⁾	Italy, 2016	Documentary prospective study	Squatting and side lying positions x lithotomy	Higher rates of severe lacerations in lithotomy position.	2C
Meyvis et al⁽¹⁹⁾	Belgium, 2012	Retrospective cross-sectional documentary study	Side lying x lithotomy	Lower laceration rates and higher intact perineum when adopting a side lying position.	1C
Thies-Lagergreen et al⁽²⁰⁾	Sweden, 2011	Controlled RCS*	Stool x lithotomy and other horizontal positions	There was no increase in non-severe and severe perineal lacerations with the use of the stool.	4A
Brément et al⁽²¹⁾	France, 2007	RCS^*	Lateral decubitus x dorsal decubitus	Lower rates of perineal lacerations in lateral decubitus.	4A
Hastings- Tolsma et al⁽²²⁾	United States^†, 2007	Retrospective documentary study	Side lying x lithotomy	Higher risk of lacerations in lithotomy position.	1C
Nasir; Korejo; Noorani⁽²³⁾	Pakistan, 2007	Case control study	Squatting x lithotomy	Reduction in perineal laceration rates in the squatting position.	2C
Ragnar et al⁽²⁴⁾	Sweden, 2006	RCS^*	All-fours x sitting	All-fours position should be encouraged by professionals.	4ª
Bodner-Adler et al⁽²⁵⁾	Austria, 2003	Case control study	Upright x supine	There was no association between horizontal position and the occurrence of perineal lacerations.	2C
Bomfim-Hyppólito⁽²⁶⁾	Brazil, 1998	RCS^*	Upright x horizontal	Lower incidence of 2^nd degree lacerations in an upright position.	2B
De Jong et al⁽²⁷⁾	South Africa, 1997	RCS^*	Upright positions vs. horizontal positions	Higher rates of lacerations in the lithotomy position; 3rd degree were slightly smaller in the upright position.	4A
Waldenstrom; Gottval⁽²⁸⁾	Sweden, 1996	RCS^*	Stool x supine	No significant differences between the two groups.	3B
Golay; Vedam; Sorger⁽²⁹⁾	United States, 1993	Cohort study	Squatting/squatting x semi-sitting	Squatting should be encouraged to prevent perineal lacerations.	1C
Gardosi; Sylvester; B-Lynch⁽³⁰⁾	England, 1989	Controlled CS^†	Squatting, knees, sitting upright or standing x lying down	Reduction of severe lacerations in the squatting position.	2B
Gardosi; Hutson; B-Lynch⁽³¹⁾	United Kingdom, 1989	Controlled RCS^*	Squatting x reclining	Higher incidence of intact perineum and lower 2^nd degree lacerations in the squatting position.	2B
Stewart;Hillan; Calder⁽³²⁾	Scotland, 1983	RCS^*	Stool (squatting) x supine position	Stool can be used for perineal preservation.	3B
Gottvall; Allebeck; Ekéus⁽³³⁾	Sweden, 2007	Cohort study	Upright positions (stool, semi-seated side leaning, squatting, all-fours, standing) x lithotomy and supine	Lithotomy and squatting may increase severe lacerations. Global effects of various positions are inconclusive.	2ª
Da Silva et al⁽³⁴⁾	Brazil, 2012	Retrospective cross-sectional study	Upright positions x supine position	Alternatives to dorsal positions can improve perineal integrity.	2B
Terry et al⁽³⁵⁾	United States, 2006	Non-randomized CS^†	Seated/squatting/all-fours x supine	Upright positions can reduce perineal lacerations.	2B
Albers et al⁽³⁶⁾	Mexico and the United States, 1996	Cohort study	Semi-seated, seated, side lying, other positions x lithotomy	Lithotomy position should not be used to prevent perineal lacerations.	1C
Maheux-Lacroix et al⁽³⁷⁾	Canada, 2013	Retrospective comparative exploratory study	Upright positions x supine position	Upright positions may be associated with lower rates of vaginal tears.	1C
Roberts; Kriz⁽³⁸⁾	United States, 1984	Retrospective correlational descriptive study	Semi-seated/All-fours/lateral birth/squatting/standing x lithotomy	It was not possible to conclude that the position influences the perineal result.	1C
Gupta; Brayshaw; Lilford⁽³⁹⁾	United Kingdom,1989	RCS^*	Squatting x lithotomy	2^nd degree lacerations were more common in the squatting position.	3A
Schirmer;Fustinoi; Basile⁽⁴⁰⁾	Brazil, 2011	RCS^*	Left side x semi-sitting upright	Higher frequency of 1^st degree lacerations in side lying position.	4A
Altman et al⁽⁴¹⁾	Sweden, 2007	RCS^*	All-fours x sitting	All-fours and sitting upright do not show significant differences in severe lacerations.	4A
Baracho et al⁽⁴²⁾	Brazil, 2009	Cohort study	Squatting/sitting/semi-sitting x supine/lithotomy	No association between horizontal position and the occurrence of perineal lacerations.	2A
Heinz et al⁽⁴³⁾	Austria, 2001	Case control study	Stool x dorsal position	Stool can be an alternative in childbirth.	2C

Summary of the Results
Upright positions compared to lithotomy positions for intact perineum
Patient or population: parturients Context: normal labor Intervention: upright positions Comparison: lithotomy positions
Outcomes	Potential absolute effects (95% CI^†)		Relative effect (95% CI*)	No. of participants (studies)	Quality of evidence (GRADE^‡)	Comments
Outcomes	Risk with lithotomy positions	Risk with upright positions	Relative effect (95% CI*)	No. of participants (studies)	Quality of evidence (GRADE^‡)	Comments
Intact perineum outcome	310 per 1,000	Risk with upright positions	RR^§ 1.04 (0.95 out of 1.14)	3083 (8 RCS*)	⨁⨁⨁⨁ HIGH
The quality levels of the GRADE working group^† High Quality: There is a lot of confidence that the real effect is close to the estimated effect Moderate Quality: There is moderate confidence in the estimated effect: The actual effect is probably close to the estimated effect, but there is a possibility that it is substantially different Low Quality: Confidence in the estimated effect is limited: the actual effect may differ substantially from the estimated effect Very Low Quality: There is very little confidence in the estimated effect: The actual effect is likely to be substantially different from the estimated effect

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E-mail: reeusp@usp.br

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[1] Corresponding author: Bruna Dedavid da Rocha Rua Martins Pena, 85 CEP 97110-490 – Santa Maria, RS, Brazil brunadedavid.rocha@gmail.com