SYNOPSIS

The influence of different maternal pushing

positions on birth outcomes at the second stage of
labor in nulliparous women

CANDIDATES NAME
DR. XXXXXXX
OBSTETRICS / GYNAECOLOGY UNIT-(XX)
XXXXXXX HOSPITAL
CITY.

CPSP REGISTRATION NUMBER: OBG-XXX-XXX-XXXX

SUPERVISOR
PROF. DR. XXXXXXXXX
MBBS (XXX)
GYNAECOLOGY AND OBSTETRICS UNIT XXX
XXXXXXXX HOSPITAL XXXX
The Director,

Research Training and Monitoring Cell.

College of Physicians & Surgeons, Pakistan

7th Central Street Phase II, DHA,

Karachi-75500

Dear Sir,

Title: The influence of different maternal pushing positions on birth outcomes at

the second stage of labor in nulliparous women

Prepared by: Dr. XXXXX

For Article writing: Obstetrics & Gynaecology

submitted on: XXXXXXXXXXX

RTMC allotted Registration Number: OBG-XXXX-XXX-XXX

Trainees Signature: __________________________

Name of Supervisor: PROF.DR. XXXX

Qualification: FCPS

Designation: Professor of Department of Gynecology & Obstetrics Unit-XX

Name of Training Institution: XXXX HOSPITAL CITY, Gynecology & Obstetrics

Signature of Supervisor: __________________________

INTRODUCTION:

In current obstetric practice, the optimum maternal position during the second stage of

labor and at delivery is unclear. Delivery has acute mental, social, and emotional effects

on the mother and the family. Therefore, management of delivery stages plays a major

role in the trend of health in about two-thirds of society members (women and children).

As labor pain is among the most acute reported pains in humans, consideration of labor

pain and its relief is an important component of maternal care in labor, such that it has

been long suggested as one of the most important issues in midwifery. Labor pain is

transferred by the stimulation of L 1L10 nerves at the first stage and, in addition to these,

S2S4 nerves at the second stage2.

The position of women during birth is determined by several factors, including cultural

background. Two major positions can be distinguished (1): horizontal (i.e., an angle of

less than 45 between the horizontal and the birth canal) and vertical (i.e., the same

angle is greater than 45). The lithotomy and left lateral positions are examples of the

horizontal position3. Examples of the vertical position include squatting, sitting, kneeling

and standing. Upright positions have become more popular since the eighteenth century

because of the potential beneficial effects on neonatal and maternal outcomes. The

squatting position during the second stage of labor has become increasingly popular in

recent years, although maternal and fetal risks and benefits are not clearly known.

Several studies have shown that all upright positions (i.e. squatting, kneeling, sitting in a

birth chair) during labor and at delivery have been associated with less severe pain,

increased pelvic dimensions, more efficient contractions, a shorter second stage of

labor, reduced risk of aortocaval compression, and improvement of acid-base outcomes

in newborns. However, there appears to be an increased postpartum hemorrhage risk in

some upright positions such as, semi-recumbent and birth seat . The squatting position is

considered to be the most natural position for various cultures including those in

Anatolia, the Middle East, and Africa, especially for women who are in the habit of

squatting to defecate1.

The routine use of the supine position in labor was introduced in the Western world

without evidence of its advantage over other positions 4. Various positions were used for

child birth in the past but supine position become popular in 17th century with the

advent of forceps. In 18th century, a French physician Francois Mauriseau, introduced

supine position to facilitate the care of women and to enhance obstetric maneuvers 5.

There are many reasons why pregnant women are in supine position during the second

stage of labor, and research has reported this - such as preference of the practitioner,

cultural influences, and hands on/hands poised preference of accoucheur 1.

Physiological advantages of squatting versus lithotomy position includes use of

gravitational force to assist patient effort to bear down, productive uterine contractions

and less aortocaval, intrauterine fetal cord compression and good perineal access 5.

In Nasir et al.'s study, two positions of standing and lithotomy (lain down on back) were

compared and it was reported that lithotomy position is appropriate for pushing as it

imposes pressure on the posterior side of vagina. Whereas, in Zaibunnisa et als study,

it was observed that lithotomy position may have some disadvantages and squatting

should be used to achieve clinical benefits. The objective of this study was to compare

the risks of delivery in squatting and lithotomy position as in past no study is done on
this obstetrical aspect at our setup. The results of the study will be shared with the

medical professionals in the field as a recommendation for future maternal positions.

OBJECTIVE:

To determine the influence of different maternal pushing positions (squatting v/s

lithotomy) on birth outcomes at the second stage of labor in nulliparous women

OPERATIONAL DEFINATIONS:

1. Squatting Position: It is defined as the position in which

patients weight is resting on her feet with knees bent 1.

2. Lithotomy position: It is defined as the position in which the

patient is lying on her back with modified to 45 degrees of

semi-fowler1.
3. Second stage of labor: It is defined as the interval between

the complete opening of the cervix until delivery of the baby1.

4. Nulliparous: A woman is regarded as nulliparous if she had

no previous pregnancies at or after 22 weeks gestation6.

MATERIAL AND METHODS:

It will be conducted at XXXX Hospital City, in Gynae / Obstetrics Unit-XX, and patients

will be included from indoors, outpatient and emergency department.

DURATION OF STUDY:

The study will be carried out for a period of 6 months after approval of synopsis.

SAMPLE SIZE:
Level of significance=5%

Power of test=90%

Sample size= 51 in each group.

SAMPLING TECHNIQUE:

Non probability consecutive sampling

STUDY DESIGN:

It will be a prospective randomized study

SAMPLE SELECTION:

Inclusion criteria:

All pregnant nulliparous women:

With singleton live cephalic presentation between 37 and 42 weeks

Who did not receive epidural anesthesia.

Exclusion criteria:

All Pregnant women with:

Previous history of uterine scar

History of pregnancy complications

fetal congenital malformations

Gestational diabetes, hypertension or chronic illness

DATA COLLECTION PROCEDURE:

Study will only be initiated after a formal approval from ethical committee of XXXX

Hospital Rawalpindi is obtained. After thorough history, examination and investigations,

patients who will give written informed consent will be included in this study.

The study is being underdone to compare 2 different delivery positions i.e. squatting vs

supine in terms of maternal and neonatal outcomes. After obtaining informed consent

from the patients, random selection will be carried out to allocate the patients to

respective groups. All patients will be given a random set of instructions. The first one

will advise the patient to adopt squatting position using bars. The second set of

instructions will encourage the use of supine lithotomy positions.

Patients will be encouraged to squat whenever they feel a strong urge to push during

the contraction. Where contractions will become infrequent, a low-dose intravenous

oxytocin infusion will be administered. For patients in the supine position, pushing will

be recommended whenever a woman felt the urge to bear down during the contraction.

Fetal heart rate will be recorded for five minutes at ten minute intervals. For

randomization to be complete, the allocated pushing position will be maintained until the

fetal head will be crowning. At this stage, all patients will be taken to the delivery table

and delivery will take place in the lithotomy position with modified to 45 degree of semi-

fowler. A medio-lateral episiotomy will be administered to some patients who are

estimated to give birth large fetuses with ultrasound calculations or who have rigid

vaginas on pelvic exam (in case of necessity).

In both groups, delivery and the third stage of labor will be conducted with the patient in

the supine position. Obstetricians and midwives will attend these births. Data will be

collected on the variables which include age, body mass index (BMI), gestational age,

educational level, presence of antenatal follow-up, presence of membrane rupture

durations, and any requirement for increased oxytocin medication. Other variables

comprise maternal hemoglobin (Hb) levels before and after delivery, postpartum

decrease in Hb level, VAS score, first and fifth minute Apgar scores, birth weight, and

NICU admission.

The primary outcome is defined as the duration of the second stage of labor. Mothers

will be asked to estimate their experience of pain during the second stage of labor on a

10-point scale (VAS score). They will be given a number of top and bottom of the scale

that represents their pain intensity (1= no pain at all, 10= unbearable pain)

DATA ANALYSIS PROCEDURE:

Data will be collected in form variables and will be stored and analyzed on SPSS

ver.20.

The average values of duration of the second stage of the labor in squatting and

supine group will be compared in the two groups using paired t-test.
In addition, the mean difference of VAS of the two groups will be compared by an

independent t-test.
Frequency and percentage will be calculated for each variable.

P value of less than 0.05 will be taken as significant.

 Title: The influence of different maternal pushing positions on birth

outcomes at the second stage of labor in nulliparous women

Name of Patient_______________________ W/O ______________ Age__________

Gravida ________ Para ____________ Gestational age_______________

Patient no_________ Contact no ______________________R/O ______________

Risk Factors

Hypertension YES/ NO
Cardiac disease YES/NO
Gestational diabetes YES/NO
Oligohydramnios YES/NO
Polyhydramnios YES/NO

GROUPS:

Group A (Squatting group)

Group B (Lithotomy/supine group)

PRIMARY OUTCOME:

Duration of Second stage of Labor: ____________

SECONDARY OUTCOME:

Abgar Score ____________

NICU Admissions: YES/NO

References:
1. Moraloglu O, Kansu-Celik H, Tasci Y et al. The influence of different maternal

pushing positions on birth outcomes at the second stage of labor in nulliparous

women. The Journal of Maternal-Fetal & Neonatal Medicine. 2016;30(2):245-

249.
2. Valiani M, Rezaie M, Shahshahan Z. Comparative study on the influence of three

delivery positions on pain intensity during the second stage of labor. Iranian

Journal of Nursing and Midwifery Research. 2016;21(4):372-378

3. Meyvis I, Rompaey B, Goormans K, Truijen S, Lambers S, Mestdagh E et al.

Maternal Position and Other Variables: Effects on Perineal Outcomes in 557

Births. Birth. 2012;39(2):115-120.

4. Walker, C., Rodrguez, T., Herranz, A. et al. Alternative model of birth to reduce

the risk of assisted vaginal delivery and perineal trauma Int Urogynecol J (2012)

23: 1249.
5. Zaibunnisa, Ara F, Ara B, Kaker P, Aslam M, Child birth; comparison of

complications between lithotomy position and squatting position during.

Professional Med J 2015;22(4):390-394.

6. Skrstad RB, Hov GG, Blaas H-GK, Romundstad PR, Salvesen K. Risk

assessment for preeclampsia in nulliparous women at 1113 weeks gestational

age: prospective evaluation of two algorithms. BJOG 2015;122:17811788.