The lithotomy position is a commonly used position in urologic, gynecologic and proctologic examinations and procedures, but is most well-known because of its widespread adoption in obstetrics. The name of the position goes back to its original use to visualize the perineal area in order to make incisions in this region to gain access for bladder stone extraction.
Patient positioning 5 - Lithotomy position
Technique and Indications
The lithotomy position has the patient lying on the dorsum with the knees, as well as the hips flexed at 90 degrees. The hips are also abducted to about 30 degrees, while the calves are supported on appropriately padded leg supports. This provides excellent surgical access to the perineum.
Indications for the lithotomy position are presented briefly below:
- Pelvic examination
- Urologic examination of the prostate
- Transurethral or perineal resection of the bladder or prostate
- Female incontinence procedures
- Ureteroscopy
- Male urethral surgery
Nerve Complications
Care should be taken to pad all points of contact between the lower limbs and the limb holders. Again, it is essential to avoid extreme flexion and abduction of the hip joint, and to minimize the time in which the limbs are required to be held in this position. It may produce stretching and compression of the nerves.
Injuries following the overuse of this position may include femoral nerve injury, peroneal nerve injury and compartment syndrome of the leg. The latter injury is characterized by a massive rise in intracompartment pressure within the leg, leading to compromised perfusion and damage to the nerves and muscles of the leg.
Obstetric Complications
There has been recent light on the adverse events associated with the use of the lithotomy position. These include:
- Restricted maternal movement during labor and delivery
- Increased trauma to the perineum and cervix
- Increased intrapartum discomfort
- Slower progress of labor and more painful contractions
- Increased need for medical intervention during all stages of labor - including labor augmentation, forceps delivery and cesarean section
- Emotional and physical trauma to the mother
- Aortocaval compression and fetal acidosis
- Neonatal respiratory distress and low Apgar scores (newborn status assessment)
- Increased rates of neonatal intensive care
Contraindications
In some conditions it is not advisable to adopt the lithotomy position, such as if there is an injury which prevents proper flexion or abduction of the hip joint. In obstetrical practice, particularly, recent research has focused on the risk-benefit ratio of this position, with special focus on the maternal and fetal outcomes.
It is, therefore, worth considering the abandonment of this position in the labor suite in favor of a more upright position. This may require physician and patient education as to the benefits of alternative birthing positions. Even with no special equipment, it is possible to adopt semi-upright positions for delivery, while the woman can remain upright throughout the first and early second stages of labor.
References
Further Reading
Concussion history identified as key risk factor for maternal mental illness