Material and methods
This secondary analysis of a multicenter randomized controlled trial [EVADELA] included 285 laboring women with ruptured membranes and a term fetus in OP position. After excluding women with cesarean deliveries before full dilatation, we compared two groups according to fetal head position at the end of the first stage of labor: those with and without rotation from OP to OA position. Factors associated with rotation were assessed with univariate and multivariate analyses using multilevel logistic regression models.
Results
The rate of anterior rotation during the first stage was 49.1%. Rotation of the fetal head was negatively associated with excessive gestational weight gain [adjusted odds ratio [aOR]: 0.37, 95% confidence interval [CI]: 0.17–0.80], macrosomia [aOR: 0.35, 95% CI: 0.14–0.90], direct OP position [aOR: 0.24, 95% CI: 0.09–0.65], and prelabor rupture of membranes [aOR: 0.40, 95% CI: 0.19–0.86]. Oxytocin administration was the only factor positively associated with fetal head rotation [aOR: 2.17, 95% CI: 1.20–3.91].
Discussion
Oxytocin administration may affect rotation of OP positions during the first stage of labor. Further studies should be performed to assess the risks and benefits of its utilization for managing labor with a fetus in OP position.
Introduction
Occiput posterior [OP] positions account for 15 to 20% of cephalic presentations at the onset of labor [1], [2], [3], [4]. Although spontaneous rotation in occiput anterior [OA] position occurs in most cases, the OP position persists at delivery in nearly 10% and is associated with obstetric complications, including prolonged labor, cesarean delivery, operative vaginal delivery, third- and fourth-degree perineal tears or lacerations, postpartum hemorrhage [PPH] and chorioamnionitis [5], [6], [7], [8], [9], [10], [11], [12]. The causation of posterior positions is multifactorial and observational studies report the following risk factors for their persistence at delivery: nulliparity, obesity, high maternal age, maternal sub-Saharan African origin, prolonged pregnancy, macrosomia, anterior placenta and epidural analgesia [1], [5], [13], [14], [15].
Nonetheless, the effectiveness of obstetric management strategies promoting the rotation of posterior positions, especially during the first stage of labor, remains to be demonstrated. Manual rotation is an effective method for turning the fetal head [16], but it is successful more often during the second stage of labor [17] and can sometimes cause fetal heart rate abnormalities, cervicovaginal injuries and in rare cases cord prolapse [18]. Another strategy uses maternal postures, such as hands-and-knees, lateral decubitus adapted to fetal station or lateral asymmetric decubitus. These are less iatrogenic and may promote earlier rotation, but randomized trials have not provided evidence of their effectiveness in promoting rotation of OP positions [19], [20], [21], [22]. Finally, other medical practices, such as analgesia, artificial rupture of membranes, or oxytocin infusion, are common during the first stage of labor, but studies that assess their effects on OP positions are lacking.
A better understanding of the factors affecting rotation of OP positions during the first stage of labor may help to promote earlier rotation and reduce obstetric complications associated with persistent OP positions. Accordingly, our principal objective was to identify maternal, neonatal and obstetric factors associated with rotation from OP to OA position during the first stage of labor. The secondary objective was to compare obstetric and neonatal outcomes associated with anterior rotation during this stage.
Section snippets
Material and methods
Our study presents a secondary analysis of data from the EVADELA multicenter randomized controlled trial [22]. This trial found no difference between lateral asymmetric decubitus posture [woman in a pronounced lateral recumbent position, lying on the side opposite that of the fetal spine, with her inferior leg positioned in the axis of the body and the upper leg hyperflexed] and a dorsal decubitus posture, for promoting the rotation of posterior positions.
The EVADELA trial recruited 322 women
Results
The fetal head rotated from an OP to an OA position during the first stage of labor for 140 [49.1%] of 285 women with a fetus in an OP position [Fig. 1]. Among women with an OP to OA rotation during the first stage, most of rotation [80.7%] occurred during the active phase of the first stage [i.e. cervical dilatation over 6 cm].
In the univariate analysis, the OP to OA rotation during the first stage was significantly more frequent for women with a gestational weight gain consistent with
Discussion
In our study, oxytocin administration during the first stage of labor was the only modifiable obstetric practice associated with OP to OA rotation. Individual factors negatively associated with rotation from OP to OA during the first stage of labor were also identified, including excessive gestational weight gain, macrosomia, direct OP position and prelabor rupture of membranes. As expected, obstetric outcomes were also better when fetus rotated from OP to OA during the first stage.
The
Ethical approval
The EVADELA trial protocol was registered in the US NIH Clinical trials database [no°NCT01854450] and approved by the Île de France XI Patient Protection Committee in February 2013 [no°13011]. Written consent of all participants was sought after antenatal and per partum information about the trial.
Contribution to authorship
All authors have made substantial contributions to: the conception and design of the study, or acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content; final approval of the version to be submitted.
Funding
Data comes from the EVADELA trial, funded by a research grant from the French Ministry of Health [CRC12002] and sponsored by the département de la recherche clinique et du développement de l’Assistance Publique–Hôpitaux de Paris.
Disclosure of interest
The authors declare that they have no competing interest.
Acknowledgments
We thank Nathalie Sellam [Pierre Rouquès–Les Bluets maternity hospital, Paris, France] and Jessy Guerin [Avranches-Granville maternity hospital, Granville, France] for their active participation in the EVADELA trial.
We thank all the women who agreed to participate in the trial and the midwives who recruited and included them. The sponsor was Assistance Publique–Hôpitaux de Paris [AP–HP, département de la recherche clinique et du développement]. The authors thank URC-CIC Paris-Descartes
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