DOI:https://doi-004.org/6812/17744226159773

Jun Zhu¹  Zhengfang Xu¹  Nian Wang¹  Ling Xu¹  Dandan Yong^1*

¹Affiliated Hospital of Jiangsu University，Zhen’jiang 212001,China

*Corresponding author：Dandan Yong

Email:yongdandan2024@163.com

Jun Zhu Email: 13775532437@163.com

Zhengfang Xu Email: Ladyada828@126.com

Nian Wang Email: 15161076201@163.com

Ling Xu Email: 15952879361@163.com

ABSTRACT

Objective: To investigate the effect of improved hand-knee position delivery on the delivery outcome and postpartum pelvic floor function of primiparas. Methods: A total of 60 primiparas in the obstetrics department of our hospital were selected as the research objects, and were divided into a control group and an observation group according to the delivery position, with 30 cases in each group. The control group adopted the conventional semi-recumbent position in the second stage of labor, while the observation group adopted the improved hand-knee position. The labor comfort, pain degree, delivery mode, labor time, blood loss during labor, perineal condition, neonatal outcome and postpartum pelvic floor function indexes were compared between the two groups. Results: The GCQ score of the observation group (75.59±1.90) was higher than that of the control group (63.09±2.07), and the VAS score of the observation group (4.32±0.47) was lower than that of the control group (8.32±0.81). The natural delivery rate of the observation group was 93.33% higher than 73.33% of the control group, the blood loss during labor was 176.19±13.17 mL less than 236.37±29.26 mL of the control group, and the time of the second stage of labor was 1.12±0.13 h shorter than 1.51±0.21 h of the control group. The integrity rate of perineum in the observation group was 46.67% higher than that in the control group (10.00%), and the lateral incision rate was 6.67% lower than that in the control group (73.33%). No neonatal birth injury occurred in the observation group, while 5 neonatal birth injury occurred in the control group. There was no significant difference in Apgar score between the two groups. Conclusion: The modified hand-knee position can improve primipara’s comfort during childbirth, promote natural childbirth, shorten the labor process, reduce perineal intervention, and improve maternal and infant outcomes, showing good clinical application potential.

Key words: improved hand-knee position; Primipara; Delivery outcomes; Pelvic floor function

1.Introduction

There are many kinds of positions that can be used by parturients during natural childbirth, such as supine position, lateral position, squat position and hand-knee position [1]. At present, the most widely used position in China is the semi-recumbent position, which is convenient for birth attendants to monitor fetal heart rate, labor process observation and delivery operation, but it is not conducive to the effective use of gravity to promote the descent of the fetal head, which may prolong the second stage of labor and increase maternal physical consumption and pain [2]. As a non-recumbent delivery position, the hand-knee position is helpful to adjust the fetal position and enlarge the pelvic diameter. It has been used to deal with abnormal delivery conditions such as shoulder dystocia. Studies have shown that this position can shorten the duration of labor, reduce lateral episiotomy, and reduce the risk of postpartum hemorrhage. However, the traditional hand-knee position needs to support the weight for a long time, which is easy to cause maternal fatigue, and it is also difficult for some women with wrist discomfort to adopt it [3]. Therefore, this study combined the delivery ball with the hand-knee position to form an improved delivery mode of hand-knee position, aiming to reduce the physical load of parturients, improve the comfort of childbirth, and further explore its effect on the delivery outcome and postpartum pelvic floor function of primiparas. The methods and results are reported as follows.

1 Objects and Methods

1.1 Subjects

A total of 60 primiparas admitted to our hospital were selected as the research objects, and were divided into two groups according to the different positions used in the delivery process, with 30 cases in each group. In the control group, the maternal age was between 22 and 35 years old, with an average age of 27.83±2.07 years old. The gestational age ranged from 37 to 41 weeks, with an average of 38.61±0.69 weeks. Their weight ranged from 55.8 to 73.5kg, with an average of 63.30±2.77kg. The abdominal circumference ranged from 95 to 106cm, with an average of 101.39±0.65cm. The uterine height measured ranged from 37 to 42cm, with a mean uterine height of 39.33±0.60cm. The maternal age of the observation group was between 21 and 34 years old, with an average age of 27.77±2.49 years old. The gestational age was 37 to 40+6 weeks, and the average gestational age was 38.35±0.71 weeks. Body weight ranged from 54.9 kg to 72.6kg, with an average of 63.59±3.21kg. The abdominal circumference ranged from 96 to 108cm, with an average of 102.09±0.63cm. Uterine height ranged from 38 to 41cm, with an average of 39.53±0.60cm. There was no significant difference in general data between the two groups (P > 0.05), suggesting that the two groups were comparable. The study protocol was reviewed and approved by the medical ethics committee of the hospital, and all enrolled parturients signed informed consent.

1.2 Inclusion and exclusion criteria

The inclusion criteria included: ① primipara with indications for natural delivery; ② age between 20 and 35 years old; ③ singleton full-term cephalic pregnancy; ④ no contraindications to delivery; ⑤ Maternal cognition and understanding ability were normal. Exclusion criteria included: (1) comorbidities such as gestational hypertension or diabetes; ② women with acute delivery; ③ complications requiring emergency intervention such as threatened rupture of uterus or severe fetal distress during labor; ④ Puerpera who received drug analgesia during labor.

1.3 Methods

During the first stage of labor, the parturients in both groups used free posture activities, and received diet and urination guidance with the help of delivery balls and other tools. The treatment of the third stage of labor was the same in the two groups.

1.3.1 In the control group, the second stage of labor was delivered in the conventional semi-recumbent position. The specific methods refer to the “Midwifery” [4]. The parturient was in a semi-reclining position, with the head of the bed raised about 50 degrees, the legs bent and extended, the feet placed on the pedals, and the hands held the handlebars beside the bed. During contractions, the midwife instructs the woman to hold her breath hard, fix her eyes on the abdomen, raise her head and tighten her jaw. During the interval of contractions, the mother will fully relax and rest. After delivery, routine neonatal evaluation and nursing care were performed. A sterile towel is then laid to assist in the delivery of the placenta, and the perineal wound is carefully examined and sutured.

1.3.2 In the observation group, the improved hand-knee position was used to deliver in the second stage of labor. First of all, a special team composed of head nurses and a number of senior midwives was established, and unified training was conducted to ensure the standardization of operation. The position process was explained in detail to the parturients before delivery to alleviate their anxiety. After the cervix is fully opened, the midwife assists the mother to kneel with her legs hip-width apart, with a soft pillow under her knees and her upper body bent over the delivery ball. During contraction, the maternal should be guided to cooperate with the force, and the lunging posture should be adopted to rest and exert force alternately. When the mother is fatigued, she can briefly change to a sitting position or a semi-recumbent position for 3 to 4 minutes, and continue after physical recovery. When the fetal head reaches 2 to 3 cm of exposure, routine disinfection towel, maintain the hand-knee position until the fetal head is delivered. The midwife does not intervene in the bending of the fetal head, only lightly support the fetal head during uterine contraction, and relax during the intermittent period. After the fetal head is crowned, the maternal should be guided to naturally deliver the fetal head with the help of uterine contraction and gravity to avoid excessive exertion. Clear the respiratory tract immediately after the fetal head is delivered, and help the shoulder to be delivered during the next contraction. After the baby was delivered, routine neonatal treatment was performed, and then the mother was assisted to complete the third stage of labor in the supine position.

1.4 Observation indicators

① Childbirth comfort and pain score. After delivery, the General ComfortQuestionnaire (GCQ) [5] was used to evaluate the comfort of childbirth, and the VisualAnalogueScale (VAS) [6] scores of the two groups in the second stage of labor were recorded. GCQ included 4 dimensions of psychological, physical, spiritual and social environment, and 28 items. Each item was scored from 1 to 4. The higher the total score, the more comfortable the patient was. VAS is a 10cm long swimming ruler marked with a scale of 0 to 10, 0 indicates no pain, 10 indicates unbearable severe pain, and the higher the score, the more severe the pain.

② Mode of delivery.

③ Maternal outcomes. The maternal perineum, the duration of the second stage of labor and the amount of blood loss during labor were recorded.

④ Neonatal outcomes. Neonatal birth trauma and Apgar score were included. Apgar score was used to score the newborns at 1 and 5min, 8-10 without asphyxia, 4-7 mild asphyxia, 0-3 severe asphyxia.

1.5 Statistical Methods

SPSS27.0 statistical software was used to process the data. The measurement data were in accordance with the normal distribution and were expressed as (). The count data were expressed as [n(%)], and the difference between the two groups was compared by test. P<0.05 was considered statistically significant.

2 Results

2.1 Comparison of comfort and pain scores between the two groups

The GCQ score of the observation group was significantly higher than that of the control group, and the VAS score of the second stage of labor was significantly lower than that of the control group, and the differences were statistically significant (P<0.05). The relevant data are shown in Table 1.

Table 1 Comparison of comfort and pain scores of puerpera in two groups (, points)

2.2 Comparison of delivery mode between the two groups

The natural delivery rate of the observation group was higher than that of the control group, and the difference was statistically significant (P<0.05). The distribution of delivery mode in the two groups is shown in Table 2.

Table 2 Comparison of delivery modes between the two groups [n(%)]

2.3 Comparison of delivery outcomes between the two groups

The amount of bleeding during labor in the observation group was less than that in the control group, the time of the second stage of labor was shorter than that in the control group, the perineum integrity rate was higher than that in the control group, and the rate of episiotomy was lower than that in the control group, and the differences were statistically significant (P<0.05). The labor process indicators and perineum conditions of the two groups are shown in Table 3 and Table 4.

Table 3 Comparison of labor process-related indicators of the two groups ()

Table 4 Comparison of perineal conditions between the two groups [n(%)]

2.4 Comparison of neonatal outcomes between the two groups

The proportion of neonatal birth injury in the observation group was lower than that in the control group, and the difference was statistically significant (P<0.05). There was no significant difference in Apgar scores between the two groups at 1 minute and 5 minutes after birth (P>0.05). The specific results are shown in Table 5.

Table 5 Comparison of neonatal outcomes between the two groups

3 Discussion

As the critical stage of fetal delivery, the second stage of labor is directly related to the safety of mother and baby. This stage of labor usually lasts for 1 to 2 hours in primiparas. If it is prolonged, it will not only increase pain, but also cause complications such as fetal distress, and even change the mode of delivery, which will have adverse effects on the health of mother and child. Therefore, shortening the duration of the second stage of labor, relieving labor pain and optimizing maternal and infant outcomes are always the focus of clinical work in obstetrics. As a common delivery position in China, the knee-fleeced supine position is convenient for midwifery operation and monitoring. However, some studies have pointed out that it may prolong the labor process, aggravate maternal pain and increase the risk of neonatal asphyxia. The World Health Organization encourages puerpera to choose the delivery position according to their own comfort [7]. In recent years, non-recumbent delivery methods such as squatting position, sitting position, lateral position and hand-knee position have gradually attracted attention. A number of studies have shown that the hand-knee position is helpful to adjust the fetal position and promote the delivery process.

The data of this study showed that the GCQ comfort score of the observation group was 75.59±1.90, which was higher than 63.09±2.07 of the control group, while the VAS pain score of the second stage of labor was only 4.32±0.47, which was significantly lower than 8.32±0.81 of the control group. The results show that the improved hand-knee position can effectively improve the comfort level of labor and reduce the pain. By analyzing the reasons, the use of the delivery ball reduced the load on the upper limbs of the parturient and made the position maintenance more labor-saving. The upper body standing upright can relieve the compression of the fetal head on the cervix and perineum, improve local blood supply, help reduce edema, and improve comfort. Corresponding studies also support this finding and point out that specific lifting position can effectively reduce labor pain, which is consistent with this conclusion [8]. In addition, lying prone on the delivery ball is also convenient for midwives to perform waist massage and press, which further relieves the waist discomfort that may be caused by lying flat. In terms of delivery mode, the natural delivery rate of the observation group was 93.33%, which was higher than 73.33% of the control group, indicating that the improved hand-knee position was helpful to promote vaginal delivery. The mechanism may include: this position makes full use of the gravity of the fetus to promote the descent; The lunging posture combined with uterine contraction can enlarge the pelvic diameter and provide more space for the fetus to pass through [9]. In support of the findings of this study, related studies have also confirmed that the hand-knee prone position can effectively manage shoulder dystocia and improve the natural delivery rate. In terms of labor process and perineal outcome, the amount of bleeding during labor in the observation group was 176.19±13.17 mL, which was less than 236.37±29.26 mL in the control group, and the time of the second stage of labor was 1.12±0.13 hours, which was shorter than 1.51±0.21 hours in the control group. At the same time, the perineum integrity rate of the observation group was 46.67%, which was higher than 10.00% of the control group. The lateral incision rate of the observation group was only 6.67%, which was much lower than 73.33% of the control group, but the perineum tear rate increased to 46.67%. This indicates that this position has advantages in promoting the progress of labor and reducing medical intervention, but it may increase the risk of perineal injury due to more emphasis on the natural delivery process and less manual assistance of fetal head flexion. It is worth noting that previous studies have shown that perineal injuries caused by delivery in the hand-knee position are mainly Ⅰ degree, while severe injuries are reduced, suggesting that such tears are usually superficial and clinically controllable [10]. In addition, improved perineal blood supply in this position may also enhance uterine contractions, thereby facilitating labor and reducing bleeding, consistent with existing literature. In terms of neonatal outcomes, no neonatal birth trauma occurred in the observation group, while 5 cases (16.67%) occurred in the control group, indicating that this delivery mode is helpful to reduce the risk of neonatal trauma. The treatment of fetal head without external force respects the natural delivery mechanism and reduces the potential injury caused by midwifery operation. The enlarged pelvic space also creates more permissive conditions for the delivery of the fetus. This position can also reduce the pressure on the uterus and large blood vessels, improve placental perfusion, and facilitate oxygen supply to the fetus. Although there was no significant difference in Apgar scores between the two groups, considering the limited sample size of this study, this result still needs to be further verified by a larger study.

In conclusion, the improved hand-knee position can effectively relieve maternal pain, improve comfort, reduce intraoperative bleeding, shorten the labor process, help to achieve natural childbirth, and reduce the risk of neonatal birth injury, showing good clinical application value.

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