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it can be caused by laceration, episiotomy, or both. This study investigated the effects of
maternal position (lateral vs lithotomy) and other variables on the occurrence of perineal
damage. Methods: A retrospective study included the examination of hospital records from
557 women. The effects of demographic characteristics, gravidity, parity, duration of
pregnancy, reason for admission, and mode of labor on perineal outcomes were investigated
through univariate (independent sample t test, chi-square test) and multivariate analysis
(logistic regression analysis). Results: Considering episiotomy as perineal damage,
univariate analysis showed a protective effect of the lateral position (45.9% vs 27.9%,
p > 0.001), and fewer episiotomies were performed (6.7% vs 38.2%) with this position. This
protective effect for perineal damage disappeared on excluding women undergoing
episiotomy from analysis. Multivariate analysis including all participants showed an
increase of 47 percent in the likelihood of an intact perineum for the lateral position when
compared with the lithotomy position (OR: 0.53; 95% CI: 0.360.78). Parity was associated
with a reduction of 44 percent in perineal damage (OR: 0.56; 95% CI: 0.470.78,
p < 0.001). Moreover, the lithotomy position was associated with significantly more
episiotomies than the lateral position (7% vs 38%, p < 0.001). The odds of perineal damage
increased in deliveries performed by physicians (OR: 2.92; 95% CI: 1.794.78).
Conclusions: Childbirth in the lateral position resulted in less perineal trauma when
compared with childbirth in the lithotomy position, even after correcting for parity and birth
attendant. The probability of an intact perineum increased in deliveries performed by
midwives. (BIRTH 39:2 June 2012)
Key words: episiotomy, lateral position, lithotomy position, maternal position, perineal
trauma
and the birth canal) and vertical (i.e., the same angle
is greater than 45). Examples of the vertical position
include squatting, sitting, and standing. The lithotomy
and left lateral positions are examples of the horizontal
116
position (1). From the year 1668 onward, a half-supine
position with the womans legs on a support has been
used by maternity practitioners as standard (1). This
position allows a view of the perineum during delivery
and facilitates maneuvers. For this reason, a more
horizontal maternal position during delivery has been
commonly adopted by birth attendants as standard
medical practice. The physiological consequences,
however, were not taken into consideration (1).
Currently the horizontal position seems to be a
prerequisite for proper continuous fetal monitoring.
This position restricts the movement of the mother
(2,3). A return to the more old-fashioned vertical
delivery has been advocated recently as a result of a
supposed increase in maternal comfort and other
advantages (4).
Perineal trauma, which is defined as any possible
damage to the perineum or the genitals, occurs
frequently after vaginal delivery, and its impact is
often underestimated by physicians and midwives (5).
The trauma could be the consequence of laceration,
episiotomy, or both. In one study, lacerations occurred
in 43 percent of the vaginal deliveries (6). In 2004,
episiotomies were performed in 23 percent of the
deliveries in the United States (6). In Belgium,
episiotomies were performed in 59 percent of all
deliveries in 2006 (7).
Perineal trauma is influenced by various risk factors,
some of which (e.g., nutritional status, maternal body
mass index, ethnic origin, birthweight, fetal position)
cannot be altered by obstetricians at the time of
delivery. Other factors (e.g., maternal position) can be
altered, thus possibly reducing perineal damage (8). In
this study, delivery in the lateral position was
compared with the lithotomy position, focusing on
perineal damage.
Methods
A study with a retrospective cross-sectional design
investigated the effects of maternal position (lateral vs
lithotomy) on perineal damage. This project was
approved by the ethical committee of ZNA
Middelheim, Antwerp, Belgium. Data collection
(demographic, medical, and obstetric data obtained
from files) in a regional general hospital started at the
beginning of November 2008 and ended in November
2009. All women with gestations between 37 and
42 weeks who were delivering vaginally were
included. Exclusion criteria were premature delivery
and any kind of operative delivery, because these
conditions could necessitate episiotomy.
The outcome was defined as perineal damage,
graded according to Fernando (9). Grade 1 refers to a
Data Analysis
Statistical analysis was performed using SPSS version
16.0 for Windows (10). Both positions (lateral vs
lithotomy) were compared using an independent
sample t test for continuous variables (presented as
mean/median and SD) and a chi-square test for
categorical variables (presented as totals and
percentages). To study the relationship between infant
birthweight and perineal damage, the ratio of infant
birthweight and infant length at birth was used as
parameter. To study the effects of position during
delivery on perineal outcomes, univariate analysis was
performed using the tests mentioned before. As a
second step, the significant variables from the
univariate analysis were entered into a logistic
regression analysis, to start with the most significant
variable and include stepwise the other variables, until
the model was complete. This step was performed by
the SPSS program automatically. It allowed the
identification of the independent predictors in one
model. The effects of these predictors can be
presented simultaneously. A p value less than 0.05
was considered significant, with a confidence interval
of 95 percent.
Results
Between November 2008 and November 2009, 1,016
women gave birth in the Antwerp hospital in Belgium
where this study was conducted, 557 of which could
be included. In 348 participants, delivery was
performed in the lithotomy position, with the other
209 deliveries performed in the lateral position.
Information on demographic characteristics, parity,
gravidity, and other obstetric factors are presented in
Table 1. Only two factors differed significantly:
women in the lateral position were older and less
likely to have epidural anesthesia than those who
delivered in the lithotomy position. Table 2 presents
information on perineal damage after birth for both
positions as a percentage. The univariate effect of
position on perineal outcome was studied with and
without episiotomy.
Women delivering in the lateral position showed
significantly more lacerations of the first and second
117
Characteristic
Age (yr) (mean/range)
Marital status (%)
Married
Cohabiting
Living alone
Origin (%)
Belgium
Morocco
Elsewhere
Gravidity (median/range)
Parity (median/range)
Gestation (wk)
Birthweight (g) (mean/range)
Duration of admission (days)
Reason for admission (%)
Spontaneous
contractions
Induction
Stimulation
Medication
Prostaglandin
Oxytocin
Both
Birth attendant (%)
Midwife
Physician
Epidural analgesia
Total
(n = 557)
Lithotomy
(n = 348)
Lateral
(n = 209)
28.1 (1545)
27.6 (1545)
29.0 (1541)
0.002
64.5
32.5
3.1
64.9
32.2
2.9
63.9
33.0
3.3
0.924
57.7
20.3
19.3
2 (112)
2 (110)
39 1
3,432 (1,9955,270)
3.8 1.4
54.3
23.0
22.7
2 (18)
2 (18)
39 1
3,451 (1,9954,830)
3.9 1.3
62.7
15.8
21.5
2 (112)
2 (110)
39 1
3,401 (2,3905,270)
3.7 1.6
0.151
0.280
0.410
0.440
0.199
0.080
55.1
52.9
58.9
23.3
21.5
23.9
23.3
22.5
18.7
1.3
42.7
5.9
1.1
46.6
5.7
1.4
36.4
6.2
0.131
0.131
14.2
85.8
44.5
46.2
70.9
50.0
53.8
29.1
35.4
<0.001
0.326
<0.001
118
The significant factors were included in a
multivariate logistic regression analysis (Table 3). This
analysis showed the protective effect of the lateral
position and parity against perineal damage. Logistic
regression showed that a one-child increase in parity
decreased the likelihood of perineal damage by 44
percent. With the lateral position the decrease in
perineal damage was 47 percent. In contrast, delivery
by a physician (compared with a midwife) and the use
of epidural analgesia resulted in a considerable
increase in perineal damage.
Discussion
Perineal damage decreased significantly for deliveries
in the lateral position. Almost 50 percent of women
delivering in the lateral position had an intact
perineum, compared with one-third of those delivering
in the lithotomy position. These results confirm earlier
studies (2,11). In a previous series, intact perineum
after a delivery was documented in up to 66 percent of
cases (12). We observed a considerable difference in
the application of episiotomy in both groups of
women. For the lateral position, fewer episiotomies
were performed, but perineal lacerations of grades 1
and 2 were significantly more common. In a recent
Episiotomy Included
Perineum
Intact
First degree
Second degree
Third degree
Episiotomy
Episiotomy followed by
laceration (%)
Total (%)
(n = 557)
p
34.6
19.4
16.2
2.3
26.4
1.1
Lithotomy
(%)
(n = 348)
27.9
16.7
13.8
2.3
38.1
1.1
Episiotomy Excluded
Lateral
(%)
(n = 209)
45.9
23.9
20.1
2.4
6.7
1.0
<0.001
0.046
0.005
0.944
<0.001
0.831
Total (%)
(n = 416)
46.4
26.7
23.3
3.6
Lithotomy
(%)
(n = 223)
Lateral (%)
(n = 193)
49.7
25.9
21.8
2.6
0.203
0.739
0.485
0.302
43.5
27.4
24.7
4.5
Univariate Analysis
Risk Factors
Lateral position
Primipara vs multipara
Physician
Epidural analgesia
Multivariate Analysis
OR (95% CI)
OR (95% CI)
0.46 (0.320.66)
0.56 (0.470.66)
3.2 (2.05.0)
1.9 (1.32.8)
<0.001
<0.001
<0.001
<0.001
0.53 (0.360.78)
0.56 (0.470.66)
2.92 (1.794.78)
0.001
<0.001
<0.001
119
Acknowledgments
We thank Thomas Slangen, who is head of the
Department of Obstetrics and Gynaecology, at the
Antwerp Hospital, Belgium, where the data were
collected.
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