Preoperative preparation for cesarean delivery is a multistep approach for which protocols should exist at each hospital system. These protocols should be guided by the findings of this review. The interventions reviewed and recommendations made for this review have a common goal of decreasing maternal and neonatal morbidity and mortality related to cesarean delivery. The preoperative period starts before the patient\'s arrival to the hospital and ends immediately before skin incision. The Centers for Disease Control and Prevention recommends showering with either soap or an antiseptic solution at least the night before a procedure. Skin cleansing in addition to this has not been shown to further decrease rates of infection. Hair removal at the cesarean skin incision site is not necessary, but if preferred by the surgical team then clipping or depilatory creams should be used rather than shaving. Preoperative enema is not recommended. A clear liquid diet may be ingested up to 2 hours before and a light meal up to 6 hours before cesarean delivery. Consider giving a preoperative carbohydrate drink to nondiabetic patients up to 2 hours before planned cesarean delivery. Weight-based intravenous cefazolin is recommended 60 minutes before skin incision: 1-2 g intravenous for patients without obesity and 2 g for patients with obesity or weight ≥80 kg. Adjunctive azithromycin 500 mg intravenous is recommended for patients with labor or rupture of membranes. Preoperative gabapentin can be considered as a way to decrease pain scores with movement in the postoperative period. Tranexamic acid (1 g in 10-20 mL of saline or 10 mg/kg intravenous) is recommended prophylactically for patients at high risk of postpartum hemorrhage and can be considered in all patients. Routine use of mechanical venous thromboembolism prophylaxis is recommended preoperatively and is to be continued until the patient is ambulatory. Music and active warming of the patient, and adequate operating room temperature improves outcomes for the patient and neonate, respectively. Noise levels should allow clear communication between teams; however, a specific decibel level has not been defined in the data. Patient positioning with left lateral tilt decreases hypotensive episodes compared with right lateral tilt, which is not recommended. Manual displacers result in fewer hypotensive episodes than left lateral tilt. Both vaginal and skin preparation should be performed with either chlorhexidine (preferred) or povidone iodine. Placement of an indwelling urinary catheter is not necessary. Nonadhesive drapes are recommended. Cell salvage, although effective for high-risk patients, is not recommended for routine use. Maternal supplemental oxygen does not improve outcomes. A surgical safety checklist (including a timeout) is recommended for all cesarean deliveries.

Late gestational supine positioning reduces maternal cardiac output due to inferior vena caval (IVC) compression, despite increased collateral venous return. However, little is known about the impact of maternal position on oxygen (O2 ) delivery and consumption of the gravid uterus, fetus, placenta and lower limbs. We studied the effects of maternal positioning on these parameters in 20 healthy pregnant subjects at 36 ± 2 weeks using magnetic resonance imaging (MRI); a follow-up MRI was performed 6-months postpartum (n = 16/20). MRI techniques included phase-contrast and T1/T2 relaxometry for blood flow and oximetry imaging, respectively. O2 transport was measured in the following vessels (bilateral where appropriate): maternal abdominal descending aorta (DAoabdo ), IVC, ovarian, paraspinal veins (PSV), uterine artery (UtA) and external iliacs, and umbilical. Maternal cardiac output was measured by summing DAothoracic and superior vena cava flows. Supine mothers (n = 6) had lower cardiac output and O2 delivery in the DAoabdo , UtA and external iliac arteries, and higher PSV flow than those in either the left (n = 8) or right (n = 6) lateral positions during MRI. However, O2 consumption in the gravid uterus, fetus, placenta and lower limbs was unaffected by maternal positioning. The ratio of IVC/PSV flow decreased in supine mothers while ovarian venous flow and O2 saturation were unaltered, suggesting a major route of pelvic venous return unaffected by maternal position. Placental-fetal O2 transport and consumption were similar between left and right lateral maternal positions. In comparison to non-pregnant findings, DAoabdo and UtA O2 delivery and pelvic O2 consumption increased, while lower-limb consumption remained constant , despite reduced external iliac artery O2 delivery in late gestation. KEY POINTS: Though sleeping supine during the third trimester is associated with an increased risk of antepartum stillbirth, the underlying biological mechanisms are not fully understood. Maternal cardiac output and uteroplacental flow are reduced in supine mothers due to inferior vena caval compression from the weight of the gravid uterus. This MRI study provides a comprehensive circulatory assessment, demonstrating reduced maternal cardiac output and O2 delivery (uteroplacental, lower body) in supine compared to lateral positioning; however, O2 consumption (gravid uterus, fetus, placenta, lower limbs) was preserved. Unlike other mammalian species, the ovarian veins conduct substantial venous return from the human pregnant uterus that is unaffected by maternal positioning. Lumbar paraspinal venous flow increased in supine mothers. These observations may have important considerations during major pelvic surgery in pregnancy (i.e. placenta percreta). Future studies should address the importance of maternal positioning as a potential tool to deliver improved perinatal outcomes in pregnancies with compromised uteroplacental O2 delivery.

OBJECTIVE: Maternal lateral postures provide advantages during childbirth. This study aims to investigate the feasibility of assisting vacuum births in maternal lateral postures in a simulation model.
METHODS: In a simulation model, four obstetricians and four medical students were randomly allocated to perform vacuum-assisted births first in maternal lateral posture or lithotomy. A modification of Aldo Vacca\'s 5-step technique was developed to assist vacuum-assisted births in lateral posture. The lateral distance, vertical distance, and distance from the cup center to the flexion point were measured for every placement of the cup.
CONCLUSIONS: A total of 128 vacuum-assisted births were performed. The mean distance to the flexion point was 1.15 ± 0.71 cm for the lithotomy posture and 1.31 ± 0.82 cm for the lateral posture (P = 0.127). There were no statistically significant differences in vacuum extractor cup placement accuracy based on maternal posture. Performing vacuum-assisted births in maternal lateral posture is feasible in a simulation model. The technique is easy to learn, and the differences in cup placement between the lateral and lithotomy postures are small.

UNASSIGNED: Fetal occiput posterior (OP) position is associated with more maternal and neonatal complications. This study aimed to investigate the effect of maternal position during labor on fetal OP position and pregnancy outcomes.
UNASSIGNED: This randomized clinical trial study included 180 primigravida women in labor with a single fetus and approved OP position. Participants were randomly allocated into three groups: semi-prone position (n=45), knee-chest position (n=45), and supine position (n=90). All participants were placed in the defined positions 15-30 min in labor until delivery. Data collected using Visual Analogue Scale and researcher made checklist. The ANOVA, Tukey post hoc, and the chi-square test were used to analyze.
UNASSIGNED: Among all participants who had OP, after intervention 16.3% in the semi-prone position, 14/3 % in the knee-chest position, and 33.7% of the control groups remained with OP at birth (X3=7/87, P=0.019). The rate of natural delivery was significantly higher in the semi-prone position and knee-chest position. The duration of active phase of labor and low back pain were significantly reduced in the semi-prone and knee-chest position compared to the control groups (P<0.05). There were no differences in the duration of the third stage of labor, APGAR score, and the rate of neonatal addition to neonatal intensive care unit, using oxytocin, and perineal tears (P>0.05).
UNASSIGNED: The semi-prone and knee-chest positions increase the spontaneous rotation of occiput to the anterior position, vaginal delivery rates as well as a reduction in duration of active phase of labor and low back pain after delivery.

OBJECTIVE: This study aimed to assess whether intrapartum ultrasound (ITU) measurements in maternal lateral posture are superimposable to ITU measurements in semi-recumbent position.
METHODS: A single-center, repeated measures design was used. Women in the second stage of labor were randomized to ITU first in semi-recumbent followed by ITU in side-lying posture without and with contraction, or inversely. The angle of progression (AOP) and the head-perineum distance (HPD) between contractions (AOP1 and HPD1) and with contraction (AOP2 and HPD2) were measured in each maternal posture. The differences between AOP1 and AOP2 (dAOP), and between HPD1 and HPD2 (dHPD) were calculated.
CONCLUSIONS: Forty-two women participated in the study. A generalized estimating equation model showed that AOP1 (-3.00°; 95 % CI -5.77 to -0.23; p = 0.03) and AOP2 (-4.14°; 95 % CI -7.20 to -1.08; p = 0.008) were lower in semi-recumbent compared to maternal lateral posture. HPD1 (+1.43 mm; 95 % CI 0.05-2.81; p = 0.042) and HPD2 (+1.53 mm; 95 % CI 0.17-2.89; p = 0.03) were higher in semi-recumbent position. Differences in the ITU measurements in maternal lateral posture compared to semi-recumbent position are small. Monitoring the second stage of labor with ITU in lateral maternal posture is possible.

Generally, combined spinal-epidural anesthesia (CSEA) for labor analgesia is performed in the lateral or sitting position; however, only few studies have investigated the effect of maternal position on labor analgesia induction. We aimed to retrospectively assess the influence of maternal position on induction time and complications.
We retrospectively analyzed anesthetic and medical records regarding labor analgesia in 201 parturients treated between January 2019 and November 2019. Patients were classified into 2 groups based on their position (sitting or lateral) during induction. The primary outcome was the time required for CSEA induction. We compared 2 groups on the primary outcome and the occurrences of other complications during CSEA induction using hyperbaric bupivacaine. Moreover, we performed multiple linear regression analysis to identify independent factors associated with induction time.
There was no significant between-group difference in the time required for induction. Multiple linear regression analysis revealed an independent association of the distance from the skin to the epidural space with the time required for induction. The lateral group had a significantly higher incidence of paresthesia than the sitting group (P = 0.028). The lateral group had a significantly higher ephedrine requirement (P < 0.001) than the sitting group.
Maternal position was not associated with the time required for CSEA induction. However, the sitting group had a lower paresthesia occurrence and ephedrine requirement than the lateral group. Other technical complications were not associated with maternal position during CSEA induction.

BACKGROUND: The existing evidence is insufficient to draw conclusions about the association between maternal position in labor and obstetrical outcomes.
OBJECTIVE: This study aimed to evaluate the effects of different maternal positions during the second stage of labor among women with and those without epidural analgesia on important obstetrical outcomes including perineal damage.
METHODS: In this retrospective cohort study, we collected data of women who delivered vaginally over a 2-year period. The associations between maternal and gestational characteristics and several obstetrical outcomes were analyzed. We considered perineal damage as the primary outcome. Secondary outcomes were the incidence of operative vaginal births, duration of fetal descent, intrapartum blood loss, and 1-minute and 5-minutes Apgar scores.
RESULTS: A total of 2240 nulliparous, at-term pregnancies were included. Of those, 76.9% gave birth in a supine position and 23.1% gave birth in alternative positions. The results showed that regardless of the use of epidural analgesia, nonsupine positions in the second stage of labor are associated with a significant reduction in the risk of both episiotomy and perineal damage to any degree (P<.0001) and to a reduction in the duration of fetal descent (Spearman rho, 9.17; confidence interval, 3.07-15.32; P=.003). No statistically significant differences were found in the 1-minute and 5-minutes Apgar score between the 2 groups.
CONCLUSIONS: Our results show that nonsupine positions in the second stage of labor and at the time of birth are associated with a significant increase in having an intact perineum and a reduction in any perineal trauma and in the need for an episiotomy regardless of the use of epidural analgesia.

Providing comfort to an antenatal mother is one of the critical components of the nonstress test (NST). An experimental study was conducted on 450 antenatal mothers beyond 34 weeks, who were randomly allocated into three groups - supine, left lateral, and semi-fowler\'s position, to explore the association of selected maternal positions on NST results and to find the impact of these positions on the comfort level of antenatal mothers. The fetal parameters were assessed by observing and recording biophysiological measurements from the NST and the maternal comfort of different positions by the Verbal Numerical Rating Scale. The data analyzed reveal a significant association between maternal positions and fetal parameters at P < 0.05 level. Antenatal women who were in semi-fowler\'s position exhibited more comfort and fetal NST reactivity as noted by significant variation in the baseline fetal heart rate, beat-to-beat variability, acceleration, deceleration, and fetal movements.

OBJECTIVE: The pain and uncertainty of the labour process can lead to anxiety. Birth ball exercises are one of the pain relief methods for the labour process. This study aimed to explore the outcomes of the use of the labour roadmap with birth balls in primiparas.
METHODS: This randomized controlled trial involved Chinese women between the gestational ages of 37-42 weeks who were randomly assigned to the experimental or control group. The outcomes of labour pain, anxiety, and self-control were collected using the Short-Form McGill Pain Questionnaire, visual analogue scale-anxiety, and Labor Agentry Scale, respectively.
RESULTS: The study found improvements in anxiety, pain, and self-control (P < 0.05), as well as the duration of the first stage of labour (P < 0.05) in the intervention group, but there were no significant differences in the duration of the second and third stages of labour, volume of bleeding, or the 1-min Apgar score between the two groups (P = 0.09, 0.07, 0.06, 0.63, respectively).
CONCLUSIONS: The labour roadmap was effective for improving self-control, reducing pain and anxiety during labour, and accelerating the first stage of labour.

BACKGROUND: The purpose of this study is to conduct an overview of Cochrane systematic reviews (SRs) evaluating the effects of maternal positions in childbirth in order to compile existing evidence for relevant research questions that have been addressed by more than one review, to provide a succinct summary of the up-to-date evidence and to identify areas for future research.
METHODS: An electronic search was conducted in the Cochrane database. Two primary outcomes were the duration of labor and birth, and operative birth. The quality of included reviews was assessed using the AMSTAR criteria, and the quality of the evidence was rated using the GRADE criteria.
RESULTS: We included 3 Cochrane SRs. There was a significant mean difference (MD) found in the duration of the first stage by 1 hour and 22 minutes (MD= -1.21; 95% CI: -2.35 - -0.07, I2=94%) and reduction in caesarean section rates (RR=0.71; 95% CI: 0.54-0.94, I2=0%) in the upright birth position group compared with the horizontal. Also, there was a statistically significant difference in the duration (minutes) of the second stage of labor (MD= -6.16; 95% CI: -9.74 - -2.59, I2=91%) and a reduction in assisted vaginal birth rates (RR=0.75, 95% CI: 0.66-0.86, I2=29%) in the upright group compared with the horizontal without epidural analgesia. The quality of evidence within the reviews was very low to moderate.
CONCLUSIONS: There is currently a limited body of evidence to clearly assess the benefits and risks of assuming upright positions during childbirth. The overview highlights the need for high-quality research studies, involving better definition and comprehensive assessment of the effects of squatting during childbirth.