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Meta-Analysis
. 2013 Mar 28;2013(3):CD007623.
doi: 10.1002/14651858.CD007623.pub3.

Maternal position during caesarean section for preventing maternal and neonatal complications

Catherine Cluver  1 , Natalia Novikova, G Justus Hofmeyr, David R Hall
Affiliations
Meta-Analysis

Maternal position during caesarean section for preventing maternal and neonatal complications

Catherine Cluver et al. Cochrane Database Syst Rev. .

Abstract

Background: During caesarean section mothers can be in different positions. Theatre tables could be tilted laterally, upwards, downwards or flexed and wedges or cushions could be used. There is no consensus on the best positioning at present.

Objectives: We assessed all available data on positioning of the mother to determine if there is an ideal position during caesarean section that would improve outcomes.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 August 2012), PubMed (1966 to 20 August 2012) and manually searched the references of retrieved articles.

Selection criteria: Randomised trials of woman undergoing caesarean section comparing different positions.

Data collection and analysis: Two review authors assessed eligibility, trial quality and extracted data.

Main results: We identified 22 studies with a total of 857 women included. We included 11 studies and excluded 11. Included trials were of variably quality with small sample sizes. Most comparisons had data from single trials. This is a shortcoming and applicability of results is limited.The incidence of air embolism was not affected by head up versus horizontal position (average risk ratio (RR) 0.85; 95% confidence interval (CI) 0.28 to 2.57; Tau² = 0.50; I² = 74%).We found no change in hypotensive episodes when comparing left lateral tilt (RR 0.11; 95% CI 0.01 to 1.94), right lateral tilt (RR 1.25; 95% CI 0.39 to 3.99), a right lumbar pelvic wedge (RR 0.85; CI 0.53 to1.37) and head down tilt (RR 1.07; 95% CI 0.81 to 1.42) with horizontal positions. We found no change in hypotensive episodes when comparing full lateral tilt with 15-degree tilt (RR 1.20; 95% CI 0.80 to 1.79). Hypotensive episodes were decreased with manual displacers (RR 0.11; 95% CI 0.03 to 0.45), and increased with a right lumbar wedge compared with a right pelvic wedge (RR 1.64; 95% CI 1.07 to 2.53) and increased with a right lateral tilt compared with a left lateral tilt (RR 3.30; 95% CI 1.20 to 9.08).Position did not affect systolic blood pressure when comparing left lateral tilt (MD 2.70; 95% CI -1.47 to 6.87) or head down tilt (MD -3.00; 95% CI -8.38 to 2.38) with horizontal positions, or full lateral tilt with 15-degree tilt (MD -5.00; 95% CI -11.45 to 1.45). Manual displacers showed decreased fall in mean systolic blood pressure compared with left lateral tilt (MD -8.80; 95% CI -13.08 to -4.52).Position did not affect diastolic blood pressures when comparing left lateral tilt versus horizontal positions (MD-1.90; 95% CI -5.28 to 1.48). The mean diastolic pressure was lower in head down tilt (MD -7.00; 95% CI -12.05 to -1.95) when compared with horizontal positions.There were no statistically significant changes in maternal pulse rate, five-minute Apgars, maternal blood pH or cord blood pH when comparing different positions.

Authors' conclusions: There is limited evidence to support or clearly disprove the value of the use of tilting or flexing the table, the use of wedges and cushions or the use of mechanical displacers. A left lateral tilt may be better than a right lateral tilt and manual displacers may be better than a left lateral tilt but larger studies with more robust data are needed to confirm these findings.

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Conflict of interest statement

None known.

Figures

1
1
Methodological quality graph: review authors' judgments about each methodological quality item presented as percentages across all included studies.
2
2
Methodological quality summary: review authors' judgments about each methodological quality item for each included study.
1.1
1.1. Analysis
Comparison 1 20º left lateral tilt versus horizontal position, Outcome 1 Hypotension.
1.2
1.2. Analysis
Comparison 1 20º left lateral tilt versus horizontal position, Outcome 2 Maternal systolic pressure at 5 minutes after spinal anaesthesia was administered.
1.3
1.3. Analysis
Comparison 1 20º left lateral tilt versus horizontal position, Outcome 3 Maternal diastolic pressure at 5 minutes after spinal anaesthesia was administered.
1.4
1.4. Analysis
Comparison 1 20º left lateral tilt versus horizontal position, Outcome 4 Maternal pulse rate at 5 minutes after spinal anaesthesia was administered.
1.5
1.5. Analysis
Comparison 1 20º left lateral tilt versus horizontal position, Outcome 5 Neonatal Apgar score less than 7 at 5 minutes.
1.6
1.6. Analysis
Comparison 1 20º left lateral tilt versus horizontal position, Outcome 6 Cord blood gas pH less than 7.2.
1.7
1.7. Analysis
Comparison 1 20º left lateral tilt versus horizontal position, Outcome 7 Umbilical artery cord blood gas pH values.
2.1
2.1. Analysis
Comparison 2 Full left lateral tilt versus a 15º left lateral tilt, Outcome 1 Hypotension.
2.2
2.2. Analysis
Comparison 2 Full left lateral tilt versus a 15º left lateral tilt, Outcome 2 Mean systolic maternal blood pressure.
3.1
3.1. Analysis
Comparison 3 Right lateral tilt versus horizontal position, Outcome 1 Hypotension.
4.1
4.1. Analysis
Comparison 4 Right lateral tilt versus left lateral tilt, Outcome 1 Hypotension.
4.2
4.2. Analysis
Comparison 4 Right lateral tilt versus left lateral tilt, Outcome 2 Hypertension.
4.3
4.3. Analysis
Comparison 4 Right lateral tilt versus left lateral tilt, Outcome 3 Maternal blood gas pH values.
4.4
4.4. Analysis
Comparison 4 Right lateral tilt versus left lateral tilt, Outcome 4 Umbilical artery cord blood gas pH values.
4.5
4.5. Analysis
Comparison 4 Right lateral tilt versus left lateral tilt, Outcome 5 Umbilical venous cord blood gas pH values.
5.1
5.1. Analysis
Comparison 5 Manual displacer versus 15º left lateral tilt, Outcome 1 Hypotension.
5.2
5.2. Analysis
Comparison 5 Manual displacer versus 15º left lateral tilt, Outcome 2 Amount of fall in systolic blood pressure mmHg.
5.3
5.3. Analysis
Comparison 5 Manual displacer versus 15º left lateral tilt, Outcome 3 Maternal mortality.
6.1
6.1. Analysis
Comparison 6 10º head down tilt versus horizontal position, Outcome 1 Hypotension.
6.2
6.2. Analysis
Comparison 6 10º head down tilt versus horizontal position, Outcome 2 Maternal systolic blood pressure.
6.3
6.3. Analysis
Comparison 6 10º head down tilt versus horizontal position, Outcome 3 Maternal diastolic blood pressure.
7.1
7.1. Analysis
Comparison 7 5º to 10º head up tilt versus horizontal position, Outcome 1 Air embolisms.
8.1
8.1. Analysis
Comparison 8 12 cm right pelvic wedge versus 12 cm right lumbar wedge, Outcome 1 Hypotension.
8.2
8.2. Analysis
Comparison 8 12 cm right pelvic wedge versus 12 cm right lumbar wedge, Outcome 2 Cord blood gas pH values.
9.1
9.1. Analysis
Comparison 9 Lumbar pelvic wedge versus horizontal position, Outcome 1 Maternal hypotension.
9.2
9.2. Analysis
Comparison 9 Lumbar pelvic wedge versus horizontal position, Outcome 2 Vomiting.
9.3
9.3. Analysis
Comparison 9 Lumbar pelvic wedge versus horizontal position, Outcome 3 Nausea.
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Update of

References

References to studies included in this review

Brock‐Utne 1978 {published data only}
    1. Brock‐Utne JG, Buley RJR, Downing JW, Cuerden C. Advantages of left over right lateral tilt for caesarean section. South African Medical Journal 1978;54(12):489‐92. - PubMed
Calvache 2011 {published data only}
    1. Calvache JA, Munoz MF, Baron FJ. Hemodynamic effects of a right lumbar‐pelvic wedge during spinal anesthesia for cesarean section. International Journal of Obstetric Anesthesia 2011;20(4):307‐11. - PubMed
Cheesman 2011 {published data only}
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Karuparthy 1989 {published data only}
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    1. Karuparthy VR, Downing JW, Husain FJ, Knape KG, Blanchard J, Solomon D, et al. Incidence of venous air embolism during cesarean section is unchanged by the use of a 5 to 10° head‐up tilt. Anaesthesia & Analgesia 1989;69(5):620‐3. - PubMed
Kundra 2007 {published data only}
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Lew 1993 {published data only}
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Matorras 1998 {published data only}
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Miyabe 1997 {published data only}
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Rees 2002 {published data only}
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Zheng 2001 {published data only}
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Zhou 2008 {published data only}
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References to studies excluded from this review

Abouleish 1980 {published data only}
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Akhtar 2011 {published data only}
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Alahuhta 1994 {published data only}
    1. Alahuhta S, Karinen J, Lumme R, Jouppila R, Hollmen AI, Jouppila P. Uteroplacental haemodynamics during spinal anaesthesia for caesarean section with two types of uterine displacement. International Journal of Obstetric Anesthesia 1994;3(4):187‐92. - PubMed
Amaro 1998 {published data only}
    1. Amaro AR, Capelli EL, Cardoso MMSC, Rosa MCR, Carvalho JCA. Manual left uterine displacement or modified Crawford's edge. A comparative study in spinal anesthesia for Cesarean delivery [Deslocamento uterino manual ou cunha de Crawford modificada? Estudo comparativo em raquianestesia para cesarianas]. Revista Brasileira De Anestesiologia 1998;48:99‐104.
Buley 1977 {published data only}
    1. Buley RJR, Downing JW, Brock‐ Utne JG, Cuerden C. Right versus left lateral tilt for caesarean section. British Journal of Anaesthesia 1977;49(10):1009‐15. - PubMed
Clemetson 1973 {published data only}
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Crawford 1972 {published data only}
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Downing 1974 {published data only}
    1. Downing JW, Coleman AJ, Mahomedy MC, Jeal DE, Mahomedy YH. Lateral table tilt for caesarean section. Anaesthesia 1974;29(6):696‐703. - PubMed
Hignett 2011 {published data only}
    1. Hignett R, Fernando R, McGlennan A, McDonald S, Stewart A, Columb M, et al. A randomized crossover study to determine the effect of a 30 degrees head‐up versus a supine position on the functional residual capacity of term parturients. Anesthesia and Analgesia 2011;113(5):1098‐102. - PubMed
Kundra 2012 {published data only}
    1. Kundra P, Velraj J, Amirthalingam U, Habeebullah S, Yuvaraj K, Elangovan S, et al. Effect of positioning from supine and left lateral positions to left lateral tilt on maternal blood flow velocities and waveforms in full‐term parturients. Anaesthesia 2012;67(8):889‐93. - PubMed
Sanchez 1985 {published data only}
    1. Sanchez JC, Gallo M, Llamas C, Torres A, Arbues J. Perinatal effects of cesarian section in left lateral position (15%) vs supine position. Archives of Gynecology 1985;237(Suppl 1):123.

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References to other published versions of this review

Cluver 2010
    1. Cluver C, Novikova N, Hofmeyr GJ, Hall DR. Maternal position during caesarean section for preventing maternal and neonatal complications. Cochrane Database of Systematic Reviews 2010, Issue 6. [DOI: 10.1002/14651858.CD007623.pub2] - DOI - PubMed

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