Perceptions of midwifery students and their lecturers regarding challenges faced by deaf pregnant women in accessing maternity care

Midwives are central to caring for pregnant women in labour, including Deaf women. It is the midwife's responsibility to communicate and establish a relationship with the pregnant woman in labour, despite the accompanying challenges. Explore fourth-year undergraduate Midwifery Students' and their Lecturers' perceptions of the challenges faced by Deaf pregnant women in accessing maternity health care when in labour. A qualitative content analysis approach with purposive sampling allowed for the invitation of Midwifery lecturers (n=2) and Bachelor of Nursing Degree Midwifery students (n=25). Data were collected through four focus group discussions and two individual interviews. Data analysis was guided by Elo and Kyngäs approach and trustworthiness was achieved. Two categories with four subcategories emerged. All pregnant women, inclusive of the often "inaudible" Deaf pregnant woman, are entitled to equitable, accessible, available person-centred maternal health care.

Relationship between COMT Gene Polymorphism, Anxiety, and Pain Perception during Labour

BACKGROUND

The COMT gene polymorphism is associated with neurological and psychiatric disorders and pain perception. The present study investigates the existence of anxiety and pain perception in relation to the COMT (catechol-O-methyltransferase) gene polymorphism in labouring women (during "natural" childbirth) with or without inhaled analgesia.

METHODS

A total of 181 women who chose vaginal birth were enrolled in this study. To present the difference in pain perception, the parturients were divided into one group (n = 90) that chose labour analgesia with inhaled nitrous oxide (50% nitrous oxide and 50% oxygen) and one group (n = 91) without analgesia. The blood samples were taken during the pregnancy as a part of routine pregnancy controls in the hospital. The COMT gene polymorphism was detected with the PCR technique. The pain perception of parturients was self-evaluated two times according to the VAS (Visual Analogue Scale), and anxiety as a personality trait was determined with the STAI-T (State Trait Anxiety Inventory). Pain perception as well as anxiety were compared according to COMT genotypes.

RESULTS

In the 181 pregnant women, there were 40 women (22%) of wild homozygotes (GG) of COMT, 95 women (53%) of mutant heterozygotes (GA), and 46 women (25%) of mutant homozygotes (AA). A negative association of pain perception with the GA (mutant heterozygote) polymorphism of the COMT gene versus the wild-type (GG polymorphism) was observed. The GA polymorphism of the COMT gene was associated with 0.46 units lower pain perception compared to the wild type (GG). The anxiety trait score in group AA was lower than in groups GA and GG. The difference reached statistical significance only when comparing AA versus GA (p > 0.042). Analgesic efficacy of nitrous oxide was noticed in 22% of labouring women who reported moderate pain (VAS score 4-7).

CONCLUSIONS

The COMT gene polymorphism was associated with pain perception and anxiety among parturients. The COMT gene polymorphism GA was associated with negative pain perception among labouring women. Nitrous oxide showed statistical significance in anxiolytic efficacy during labour in women with mild anxiety as a personality trait. Anxiolytic efficacy of nitrous oxide has shown better efficacy in parturients with the COMT gene polymorphism AA.

Impacts of disrespectful care and abusive care practices in maternity units and potential interventions to improve the quality of care in low- and middle-income countries: A narrative review

This review article explored the impacts of disrespectful care and abusive care practices and the potential interventions to eliminate those practices. Respectful maternity care is a fundamental right for all women. It ensures that women are able to exercise their rights in maternity care. However, research studies have shown the recent prevalence of poor-quality care for women in maternity units in low- and middle-income countries. The literature on this topic was searched on PubMed, Medline, Google Scholar, Cochrane, Science Direct/ Elsevier, and SCOPUS. A total of 24 qualitative and quantitative research articles were included. Thematic analysis was conducted by using the six steps. Impacts are coded on topics including psychological impacts due to disrespectful and abusive care practices, impact on the care process, normalization of the absence of care, suppression of knowledge regarding the labor process, and poor obstetric outcomes. Interventions are coded on topics including programs for health professionals to improve care, education and empowerment programs targeting the women and community, enacting policies and guidelines regarding disrespectful and abusive care practices and improving the facilities in the healthcare system. The majority of the evidenced-based interventions were multi-component and tailored to the needs of a particular setting. More research evidence is needed to inform the healthcare authorities and policymakers to transform these potential interventions into practice. Future research should clearly document the effectiveness of various combinations of interventions, feasibility, cost-effectiveness, and outcomes.

Family centered nursing practices towards women and their families in the birthing context: A qualitative systematic review

AIM

Synthesize qualitative evidence examining how nurses' attitudes, beliefs, and sense of efficacy and the context surrounding birth facilitate or hinder family-centered nursing practice.

DESIGN

Thematic synthesis of qualitative studies.

METHODS

A literature search was conducted in CINAHL, MEDLINE, PsycINFO, SCOPUS, SCIENCE DIRECT, REPÈRES, CAIRN, and ÉRUDIT from October 2020 to June 2021. The PRISMA guidelines were followed, and studies were critically appraised using the Critical Appraisal Skills Programme checklist. Data were extracted by two independent reviewers, and Thomas and Harden's qualitative thematic synthesis method was performed for data analysis.

RESULTS

Thirteen studies were included. Three analytical themes were generated: (1) sharing power: opposing beliefs, (2) feeling a sense of efficacy in fulfilling one's role, and (3) managing a challenging work environment.

PATIENT OR PUBLIC CONTRIBUTION

Synthesizing nurses' experience is essential to promote implementation of favourable changes for care that is more focused on the needs of families.

Safety and Effect of the Use of Hydrotherapy during Labour: A Retrospective Observational Study

BACKGROUND

Hydrotherapy is a technique used for pain management during labour, but its safety for both the mother and foetus remains uncertain.

OBJECTIVE

The main aim of this study is to determine whether the use of hydrotherapy in the first stage of labour is safe for both the mother and newborn.

METHODS

A retrospective observational study was conducted to collect data from the partogram, maternal and neonatal history.

RESULTS

A total of 377 women who gave birth at the Costa del Sol Hospital in Malaga between January 2010 and December 2020 were randomly selected. They were divided into a control group (253 women) and an intervention group (124 women) that used hydrotherapy in the first stage of labour. There were no significant differences between the groups in terms of age, history of previous miscarriages, type of delivery, or newborn weight. The results showed that most women who opted for hydrotherapy were nulliparous, and the use of hydrotherapy during labour was safe for both the mother and foetus. There were no significant differences in the variables of maternal arterial hypotension, postpartum haemorrhage, postpartum maternal fever, foetal complications, neonatal admission, 1 and 5 min Apgar scores, umbilical arterial or venous pH, or foetal cardiotocographic recording. However, there was a significant difference (p = 0.005) in the rate of breastfeeding among mothers who opted for hydrotherapy (96% vs. 85.7%).

CONCLUSIONS

The use of hydrotherapy during the first stage of labour is safe and is associated with increased breastfeeding rates compared to conventional delivery.

Does antenatal cholecalciferol supplementation affect the mode or timing of delivery? Post hoc analyses of the MAVIDOS randomized controlled trial

BACKGROUND

Observational studies relating maternal 25-hydroxyvitamin D status to timing and mode of delivery have reported inconsistent results. We assessed the effect of antenatal cholecalciferol supplementation on the incidence of preterm birth, delivery mode and post-partum haemorrhage (PPH).

METHODS

MAVIDOS was a randomized, double-blind, placebo-controlled trial of 1000 IU/day cholecalciferol from 14 weeks' gestation until delivery. Gestational age, mode of delivery [categorized as spontaneous vaginal delivery (SVD), instrumental (including forceps and vacuum extraction) or Caesarean section] and PPH (>500 ml estimated blood loss) were determined from medical records.

RESULTS

A total of 965 women participated in the study until delivery. Gestation at birth and incidence of preterm birth (cholecalciferol 5.7%, placebo 4.5%, P = 0.43) were similar between the two treatment groups. SVD (versus instrumental or Caesarean delivery) was more likely in women randomized to cholecalciferol [Relative Risk (RR) 1.13, 95% confidence interval (CI) 1.02,1.25] due to lower instrumental (RR 0.68, 95%CI 0.51,0.91) but similar risk of Caesarean delivery (RR 0.94, 95%CI 0.74,1.19). PPH was less common in women randomized to cholecalciferol [32.1% compared with placebo (38.1%, P = 0.054) overall], but similar when stratified by delivery mode.

CONCLUSIONS

Antenatal cholecalciferol supplementation did not alter timing of birth or prevalence of preterm birth but demonstrated a possible effect on the likelihood of SVD.

Minimum effective dose of oxytocin bolus during the caesarean section for patients at high vs low risk of uterine atony: A non-randomized, dual-arm, dose-finding prospective trial

Background and Aims

There are scanty data for oxytocin dose in patients at high risk of uterine atony. We aimed to compare the effective dose (ED) 90 of oxytocin for adequate uterine tone during the caesarean section in patients at high-risk vs low-risk uterine atony.

Methods

This dose-finding study was undertaken after ethical approval in non-labouring women aged >18 years with pre-defined risk factors for uterine atony (high-risk group) vs those without such factors (low-risk group) (n = 39 each). Starting dose of oxytocin in the first patient of low-risk and high-risk groups was 1 and 3 IU, respectively. Achieving adequate uterine tone at 3 min of oxytocin bolus was designated 'success', while inadequate tone constituted 'failure'. If the response was 'failure', the dose of oxytocin was increased for the next patient by 0.5 or 0.2 IU (high- and low-risk groups, respectively). In case of a successful response, the dose for the next patient was decreased with a probability of 1/9 using the same dosing intervals or otherwise kept unchanged.

Results

The ED90 (95% CI) of oxytocin bolus was 4.7 (3.3-6.0) IU for the high-risk group and 2.2 (1.3-3.2) IU for the low-risk group (P = 0.044). Oxytocin-associated tachycardia (P = 0.247) and hypotension (P = 0.675) were clinically greater for the high-risk vs low-risk group but statistically similar.

Conclusion

Non-labouring patients with high-risk factors for uterine atony require a greater dose of initial oxytocin bolus to achieve adequate uterine tone during the caesarean section compared to those without risk factors.

Prostaglandin F2α requires activation of calcium-dependent signalling to trigger inflammation in human myometrium

Introduction

Preterm birth is one of the major causes of neonatal morbidity and mortality across the world. Both term and preterm labour are preceded by inflammatory activation in uterine tissues. This includes increased leukocyte infiltration, and subsequent increase in chemokine and cytokine levels, activation of pro-inflammatory transcription factors as NF-κB and increased prostaglandin synthesis. Prostaglandin F2α (PGF2α) is one of the myometrial activators and stimulators.

Methods

Here we investigated the role of PGF2α in pro-inflammatory signalling pathways in human myometrial cells isolated from term non-labouring uterine tissue. Primary myometrial cells were treated with G protein inhibitors, calcium chelators and/or PGF2α. Nuclear extracts were analysed by TranSignal cAMP/Calcium Protein/DNA Array. Whole cell protein lysates were analysed by Western blotting. mRNA levels of target genes were analysed by RT-PCR.

Results

The results show that PGF2α increases inflammation in myometrial cells through increased activation of NF-κB and MAP kinases and increased expression of COX-2. PGF2α was found to activate several calcium/cAMP-dependent transcription factors, such as CREB and C/EBP-β. mRNA levels of NF-κB-regulated cytokines and chemokines were also elevated with PGF2α stimulation. We have shown that the increase in PGF2α-mediated COX-2 expression in myometrial cells requires coupling of the FP receptor to both Gαq and Gαi proteins. Additionally, PGF2α-induced calcium response was also mediated through Gαq and Gαi coupling.

Discussion

In summary, our findings suggest that PGF2α-induced inflammation in myometrial cells involves activation of several transcription factors - NF-κB, MAP kinases, CREB and C/EBP-β. Our results indicate that the FP receptor signals via Gαq and Gαi coupling in myometrium. This work provides insight into PGF2α pro-inflammatory signalling in term myometrium prior to the onset of labour and suggests that PGF2α signalling pathways could be a potential target for management of preterm labour.

Managing Labour in Women with COVID-19

Since first reported in December 2019 in Wuhan, China, COVID-19 caused by Severe Acute Respiratory Syndrome (SARS) Corona virus2 (SARS CoV-2) quickly spread to become a pandemic that has caused significant morbidity and mortality. The rapidity of the spread of the virus and the high mortality at the outset threatened to overwhelm health systems worldwide, and, indeed, this significantly impacted maternal health, especially since there was minimal experience to draw from. Experience with Covid 19 has grown exponentially as the unique needs of pregnant and labouring women with COVID-19 infection have become more evident. Managing COVID-19 parturients requires a multidisciplinary team consisting of anaesthesiologists, obstetricians, neonatologists, nursing staff, critical care staff, infectious disease and infection control experts. There should be a clear policy on triaging patients depending on the severity of their condition and the stage of labour. Those at high risk of respiratory failure should be managed in a tertiary referral centre with facilities for intensive care and assisted respiration. Staff and patients in delivery suites and operating rooms should be protected by enforcing infection protection principles such as offering dedicated rooms and theatres to SARS CoV-2 positive patients and using personal protective equipment. All hospital staff must be trained in infection control measures which should be updated regularly. Breastfeeding and care of the new-born must be part of the healthcare package offered to COVID-19 parturient mothers.

Unusual Presentation of Pneumocephalus With Late Onset During Labour Epidural Analgesia

A 36-year-old woman with no significant medical history was in active labour and requested labour analgesia. While the epidural technique was performed at the L4-L5 interspace, using the loss of resistance to air technique (LORA), inadvertent dural puncture occurred. Since the patient reported no headache or discomfort, the same procedure was repeated at the L3-L4 interspace successfully. Loss of resistance was reported at 3 cm and the epidural catheter was advanced uneventfully at 8 cm. Aspiration was negative for blood or cerebrospinal fluid (CSF) and a test dose of 2 ml lidocaine 2% was administered epidurally. Within five minutes the patient exhibited a mild hypotensive episode successfully treated with 2.5 mg ephedrine IV, a sensory blockade up to T6 level, and a motor blockade up to T10 level. Both the woman's and the baby's vital signs remained stable, no further drugs were administered epidurally and labour progressed painlessly and uncomplicated for 90 minutes with subsequent vaginal delivery of a healthy newborn. During the episiotomy incision repair, the patient complained of light dizziness and nausea. Her vital signs and the arterial blood gases (ABGs) ordered were within normal range, but the neurological examination revealed an isolated Babinski on the right foot. The head CT scan requested indicated a considerable quantity of air within the subarachnoid region. The patient was treated conservatively; symptoms showed steady improvement with total resolution on the sixth day, and the woman was discharged. This case reemphasizes the possibility of pneumocephalus, which may, in reality, occur more frequently than is commonly recognized without a CT confirmation.

Childbirth expectations and coping strategies of first-time mothers attending a comprehensive health centre in Ekiti State, Nigeria

Childbirth is a complex life event for every woman. Women will have positive experiences if their expectations are met during childbirth, unmet expectations can result in negative experience. This study assessed the knowledge, expectations and coping strategies used by first time mothers attending a Comprehensive Health Center in Ekiti State. The study adopted a qualitative research design and twenty individual semi-structured interviews were conducted. Purposive sampling technique was used and the sample size was determined by saturation of data. Interviews were analyzed using qualitative thematic content analysis. Findings revealed limited knowledge about labour as majority of the participants had no knowledge of labour signs and process. Also, almost all the women were not familiar with the various methods for relief from discomfort during labour and first-time mothers expect midwives to care for them throughout the labour process. This study emphasized the need for healthcare professionals to provide suitable comprehensive education on the process and signs of labor as well as the various methods of pain relief. Supportive networks should also be provided for women during prenatal clinics. Also, health care professionals should consider the needs of mothers and try as much as possible to provide holistic support.

Effectiveness of antepartum breathing exercises on the outcome of labour: A randomized controlled trial

Background Childbirth is a life-transforming intense event to a woman and her family. Even though a variety of non-pharmacological techniques are readily available to alleviate the distress of women in labour, the majority of women are unaware of its benefits. The objective of the study was to explore the impact of a simple non-pharmacological technique i.e., antepartum breathing exercises on maternal outcomes of labour among primigravid women. Methods A single centre prospective, single-blinded, randomized controlled trial was conducted at the antenatal outpatient clinic of a secondary healthcare institution. Eligible primigravid women were randomized into intervention and standard care groups. Both groups received standard obstetrical care. In addition, the intervention group were taught antepartum breathing exercises and were advised to practise daily and also during the active stage of labour. The primary outcome of the trial was the maternal outcome of labour measured in terms of onset of labour, nature of delivery, duration of labour, and need for augmentation of labour. Data was collected using World Health Organization (WHO) partograph, structured observational record on the outcome of labour. Results A total of 98 (70%) primigravid women who practised antepartum breathing exercises had spontaneous onset of labour. The odds of spontaneous onset of labour after randomization in the intervention group was 2.192 times more when compared to standard care at a (95% confidence interval 1.31-3.36, p<.001). Also, the requirement for augmentation of labour was minimal and there was a reduction in the rate of caesarean deliveries ( p <.05) based on the χ2 test. The overall mean duration of labour was less compared to standard care group F(1)= 133.800, p <.001. Conclusion Antepartum breathing exercises during labour can facilitate spontaneous vaginal birth, shorten the duration of labour, and reduce the need for operative interference.

Integrating single-cell RNA sequencing with spatial transcriptomics reveals an immune landscape of human myometrium during labour

BACKGROUND

The transition of the myometrium from a quiescent to a contractile state during labour is known to involve inflammation, which is characterized by the infiltration of immune cells and the secretion of cytokines. However, the specific cellular mechanisms underlying inflammation in the myometrium during human parturition are not yet fully understood.

METHODS

Through the analysis of transcriptomics, proteomics, and cytokine arrays, the inflammation in the human myometrium during labour was revealed. By performing single-cell RNA sequencing (scRNA-seq) and spatiotemporal transcriptomic (ST) analyses on human myometrium in term in labour (TIL) and term in non-labour (TNL), we established a comprehensive landscape of immune cells, their transcriptional characteristics, distribution, function and intercellular communications during labour. Histological staining, flow cytometry, and western blotting were applied to validate some results from scRNA-seq and ST.

RESULTS

Our analysis identified immune cell types, including monocytes, neutrophils, T cells, natural killer (NK) cells and B cells, present in the myometrium. TIL myometrium had a higher proportion of monocytes and neutrophils than TNL myometrium. Furthermore, the scRNA-seq analysis showed an increase in M1 macrophages in TIL myometrium. CXCL8 expression was mainly observed in neutrophils and increased in TIL myometrium. CCL3 and CCL4 were principally expressed in M2 macrophages and neutrophils-6, and decreased during labour; XCL1 and XCL2 were specifically expressed in NK cells, and decreased during labour. Analysis of cytokine receptor expression revealed an increase in IL1R2, which primarily expressed in neutrophils. Finally, we visualized the spatial proximity of representative cytokines, contraction-associated genes, and corresponding receptors in ST to demonstrate their location within the myometrium.

CONCLUSIONS

Our analysis comprehensively revealed changes in immune cells, cytokines, and cytokine receptors during labour. It provided a valuable resource to detect and characterize inflammatory changes, yielding insights into the immune mechanisms underlying labour.

Creative arts workers during the Covid-19 pandemic: Social imaginaries in lockdown

The arts and creative industries are among those most affected by government measures to contain the Covid-19 pandemic. This article discusses a qualitative survey study, open between August and October 2020, with creative arts workers living in Victoria, Australia. The study explored experiences of disruptions to work and broader impacts on daily lives during the pandemic. In this article, we examine how participants discuss their work and circulate pre-existing and create new intensified social imaginaries of a devalued and ignored arts sector in Australia. Our analysis points to how people understand their lives, work and communities amidst a global pandemic in relation to and entangled with particular social imaginaries of the creative arts.

Clinical characteristics and predictors of neonatal outcomes in chorioamnionitis at term gestation: A cohort study

OBJECTIVE

To investigate the association between clinical and laboratory characteristics of chorioamnionitis in deliveries at term gestation with adverse neonatal outcomes.

DESIGN

Retrospective cohort study.

SETTING

The study is based on data from the Swedish Pregnancy Register, enriched with clinical data extracted from medical charts.

SAMPLE

A cohort of 500 term singleton deliveries in Stockholm County with registered diagnosis of chorioamnionitis (based on the assessment of the responsible obstetrician) in the Swedish Pregnancy Register between 2014 and 2020.

METHODS

Logistic regression was used to estimate odds ratios (ORs) as a measurement of the association between clinical and laboratory characteristics and neonatal complications.

MAIN OUTCOME MEASURES

Neonatal infection and asphyxia-related complications.

RESULTS

The prevalence of neonatal infection and asphyxia-related complications was 10% and 22%, respectively. First leukocyte count in the second tertile (OR 2.14, 95% CI 1.02-4.49), maximum C-reactive protein (CRP) level in the third tertile (OR 4.01, 95% Cl 1.66-9.68) and positive cervical culture (OR 2.22, 95% Cl 1.10-4.48) were associated with an increased risk of neonatal infection. Maximum level of CRP in the third tertile (OR 1.93, 95% Cl 1.09-3.41) and fetal tachycardia (OR 1.63, 95% Cl 1.01-2.65) were associated with an increased risk of asphyxia-related complications.

CONCLUSIONS

Elevated inflammatory laboratory markers were associated with both neonatal infection and asphyxia-related complications, and fetal tachycardia was associated with asphyxia-related complications. Based on these findings, the incorporation of maternal CRP in the management of chorioamnionitis should be considered, and a continuous communication between obstetric and neonatal care extending past the delivery time point endorsed.

Midwives' perspectives of intravenous fluid management and fluid balance documentation in labour: A qualitative reflexive thematic analysis study

AIM

To describe current practice, examine the influences and explore barriers and facilitators to accurate documentation, for the administration of intravenous fluids during labour.

DESIGN

A descriptive qualitative study was performed.

METHODS

Qualitative semi-structured interviews were conducted with Registered Midwives working across Australia. Midwives were recruited via email and social media advertisements. A maximum variation sampling strategy was used to identify potential participants. Interview questions explored four main areas: (i) understanding of indications for IV fluids in labour; (ii) identification of current practice; (iii) barriers to documentation and (iv) benefits and complications of IV fluid administration. Reflexive thematic analysis of recorded-transcribed interviews was conducted.

RESULTS

Eleven midwives were interviewed. Clinical practice variation across Australia was recognized. Midwives reported a potential risk of harm for women and babies and a current lack of evidence, education and clinical guidance contributing to uncertainty around the use of IV fluids in labour. Overall, eight major themes were identified: (i) A variable clinical practice; (ii) Triggers and habits; (iii) Workplace and professional culture; (iv) Foundational knowledge; (v) Perception of risk; (vi) Professional standards and regulations; (vii) The importance of monitoring maternal fluid balance and (viii) barriers and facilitators to fluid balance documentation.

CONCLUSION

There was widespread clinical variation identified and midwives reported a potential risk of harm. The major themes identified will inform future quantitative research examining the impact of IV fluids in labour.

IMPACT

The implications of this research are important and potentially far-reaching. The administration of IV fluids to women in labour is a common clinical intervention. However, there is limited evidence available to guide practice. This study highlights the need for greater education and evidence examining maternal and neonatal outcomes to provide improved clinical guidance.

A prospective cohort study comparing neonatal outcomes of waterbirth and land birth in an Australian tertiary maternity unit

BACKGROUND

Maternal preference for warm water immersion (WWI) and waterbirth is increasing, but adoption into obstetric guidelines and clinical practice remains limited. Concerns regarding safety and a paucity of evidence have been cited as reasons for the limited adoption and uptake.

AIM

The aim was to investigate maternal and neonatal outcomes after WWI and/or waterbirth compared with land birth.

MATERIALS AND METHODS

A prospective cohort study was conducted in an Australian public maternity hospital between 2019 and 2020. Maternal and neonatal outcomes for 1665 women who had a vaginal birth were studied. Primary outcome was admission to the neonatal unit (NNU). Secondary outcomes included neonatal antibiotic administration, maternal intrapartum fever, epidural use and perineal injury. Multivariate logistical regression analyses compared the outcomes between three groups: waterbirth, WWI only and land birth.

RESULTS

NNU admissions for a suspected infectious condition were significantly higher in the land birth group (P = 0.035). After accounting for labour duration, epidural use and previous birth mode, no significant difference was detected between groups in the odds of NNU admission (P = 0.167). No babies were admitted to NNU with water inhalation or drowning. Women birthing on land were more likely to be febrile (2 vs 0%; P = 0.007); obstetric anal sphincter injury and postpartum haemorrhage were similar between groups. Regional analgesia use was significantly lower in the WWI group compared to the land birth group (21.02 vs 38.58%; P = <0.001). There was one cord avulsion in the waterbirth group (0.41%).

CONCLUSION

Maternal and neonatal outcomes were similar between groups, with no increased risk evident in the waterbirth and WWI groups.

Trends and regional variations in prescriptions dispensed to stimulate uterine contractions at the end of pregnancy in Belgium: A community-based study from 2003 to 2018

PURPOSE

To investigate trends and regional variations in uterotonics dispensed around birth between 2003 and 2018 in Belgium.

METHODS

Data, including outpatient and inpatient prescriptions were extracted from a nationally representative prescription database. The prevalence of uterotonics dispensed during a period including the 7 days before birth, the delivery day and the 7 days after birth was computed over three 4-year-long study periods from 2003 to 2018. The trends between periods and associations between the use of at least one uterotonic and maternal age, region of residence, delivery type and social status were assessed using logistic regression.

RESULTS

In total, 31 675 pregnancies were included in the study. The proportion of pregnancies exposed to at least one uterotonic decreased significantly from 92.9% (95%CI, 92.3-93.4) in 2003-2006 to 91.4% (95%CI, 90.7-92.0) in 2015-2018 for vaginal births and from 95.5% (95%CI, 94.5-96.4) to 93.7% (95%CI, 92.6-94.7) for caesarean sections. However, for vaginal births, the proportion of oxytocin increased from 84.5% (95%CI, 83.7-85.2) to 89% (95%CI 88.3-89.7). A significant association was found between uterotonic agent use and maternal age, region of residence, and delivery type. The dispensation of some uterotonic agents differed significantly between the regions.

CONCLUSIONS

The proportion of pregnancies exposed to at least one uterotonic was high across the study period but decreased slightly between 2003 and 2018. Important variations in uterotonic use between regions highlight the need for improved national guidance.

Guideline No. 432c: Induction of Labour

OBJECTIVES

This guideline presents evidence and recommendations for cervical ripening and induction of labour. It aims to provide information to birth attendants and pregnant individuals on optimal perinatal care while avoiding unnecessary obstetrical intervention.

TARGET POPULATION

All pregnant patients.

BENEFITS, RISKS, AND COSTS

Consistent interprofessional use of the guideline, appropriate equipment, and trained professional staff enhance safe intrapartum care. Pregnant individuals and their support person(s) should be informed of the benefits and risks of induction of labour.

EVIDENCE

Literature published to March 2022 was reviewed. PubMed, CINAHL, and the Cochrane Library were used to search for systematic reviews, randomized control trials, and observational studies on cervical ripening and induction labour. Grey (unpublished) literature was identified by searching the websites of health technology assessment and health technology related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

All providers of obstetrical care.

SUMMARY STATEMENTS

Misoprostol OXYTOCIN: RECOMMENDATIONS.

Guideline No. 432b: Cervical Ripening

OBJECTIVE

This guideline presents evidence and recommendations for cervical ripening and induction of labour. It aims to provide information to birth attendants and pregnant individuals on optimal perinatal care while avoiding unnecessary obstetrical intervention.

TARGET POPULATION

All pregnant patients.

BENEFITS, HARMS, AND COSTS

Consistent interprofessional use of the guideline, appropriate equipment, and trained professional staff enhance safe intrapartum care. Pregnant individuals and their support person(s) should be informed of the benefits and risks of induction of labour.

EVIDENCE

Literature published to March 2022 was reviewed. PubMed, CINAHL, and the Cochrane Library were used to search for systematic reviews, randomized controlled trials, and observational studies on cervical ripening and induction of labour. Grey (unpublished) literature was identified by searching the websites of health technology assessment and health technology related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

All providers of obstetrical care.

RECOMMANDATIONS

How should we interpret lactate in labour? A reference study

OBJECTIVE

To investigate maternal lactate concentrations in labour and the puerperium.

DESIGN

Reference study.

SETTING

Tertiary obstetric unit.

POPULATION

1279 pregnant women with good perinatal outcomes at term.

METHODS

Electronic patient records were searched for women who had lactate measured on the day of delivery or in the following 24 hours, but who were subsequently found to have a very low likelihood of sepsis, based on their outcomes.

MAIN OUTCOME MEASURES

The normative distribution of lactate and C-reactive protein (CRP), differences according to the mode of birth, and the proportion of results above the commonly used cut-offs (≥2 and ≥4 mmol/l).

RESULTS

Lactate varied between 0.4-5.4 mmol/l (median 1.8 mmol/l, interquartile range [IQR] 1.3-2.5). It was higher in women who had vaginal deliveries than caesarean sections (median 1.9 vs. 1.6 mmol/l, p_diff  < 0.001), demonstrating the association with labour (particularly active pushing in the second stage). In contrast, CRP was more elevated in women who had caesarean sections (median 71.8 mg/l) than those who had vaginal deliveries (33.4 mg/l, p_diff  < 0.001). In total, 40.8% had a lactate ≥2 mmol/l, but 95.3% were <4 mmol/l.

CONCLUSIONS

Lactate in labour and the puerperium is commonly elevated above the levels expected in healthy pregnant or non-pregnant women. There is a paucity of evidence to support using lactate or CRP to make decisions about antibiotics around the time of delivery but, as lactate is rarely higher than 4 mmol/l, this upper limit may still represent a useful severity marker for the investigation and management of sepsis in labour.

Post-partum Hamman's Syndrome

Hamman's syndrome is an uncommon complication of labor. Its diagnosis is based on clinical suspicion and CT imaging. It is often a benign and self-limiting condition occurring in healthy patients. The risk factors are nulliparity and a prolonged second stage of labor. Hamman's syndrome has life-threatening implications that underscore the importance of early diagnosis and management to avoid any difficulty. This paper discusses the case of a 21-year-old, healthy female without allergies who was admitted to the hospital in spontaneous labor at 40 weeks of gestation. During the second stage of labor, she developed Hamman's syndrome and presented with subcutaneous emphysema, which led to an emergency C-section. After a chest and cervical CT scan that showed extensive subcutaneous emphysema and a pneumomediastinum, the patient was admitted to the ICU.

Put your weight behind it-Effect of body mass index on the active second stage of labour: A retrospective cohort study

OBJECTIVE

To explore the duration of the active phase of the second stage of labour in relation to maternal pre-pregnant body mass index (BMI).

DESIGN

Retrospective cohort study.

SETTING

Labour wards of three Norwegian university hospitals, 2012-2019.

POPULATION

Nulliparous and parous women without previous caesarean section with a live singleton fetus in cephalic presentation and spontaneous onset of labour, corresponding to the Ten Group Classification System (TGCS) group 1 and 3.

METHODS

Women were stratified to BMI groups according to WHO classification, and estimated median duration of the active phase of the second stage of labour was calculated using survival analyses. Caesarean sections and operative vaginal deliveries during the active phase were censored.

MAIN OUTCOME MEASURES

Estimated median duration of the active phase of second stage of labour.

RESULTS

In all, 47 942 women were included in the survival analyses. Increasing BMI was associated with shorter estimated median duration of the active second stage in both TGCS groups. In TGCS group 1, the estimated median durations (interquartile range) were 44 (26-75), 43 (25-71), 39 (22-70), 33 (18-63), 34 (19-54) and 29 (16-56) minutes in BMI groups 1-6, respectively. In TGCS group 3, the corresponding values were 11 (6-19), 10 (6-17), 10 (6-16), 9 (5-15), 8 (5-13) and 7 (4-11) minutes. Increasing BMI remained associated with shorter estimated median duration in analyses stratified by oxytocin augmentation and epidural analgesia.

CONCLUSION

Increasing BMI was associated with shorter estimated median duration of the active second stage of labour.

'Pregnant women voice their concerns and delivery method preferences during the COVID-19 pandemic in Turkey'

OBJECTIVE

To evaluate pregnant women's voice their concerns and delivery method preferences during the COVID-19 pandemic in Turkey.

Methods: A cross-sectional study is survey based using an online survey platform. Three hundred pregnant women were included between 16 May and 12 June 2020 in Turkey. Sociodemographic features, obstetric features, concerns about COVID-19, delivery method preferences, and Brief Measure of Worry Severity were evaluated.

RESULTS

It was determined that the concerns of pregnant women about the pandemic were moderate (12.73 ± 6.838) and did not alter their delivery method preferences. However, the concerns of the pregnant women who planned to perform their delivery by caesarean section before COVID-19 and whose delivery method preferences changed during the pandemic process were higher (p < 0.05). Additionally, during the COVID-19 period, pregnant women often harbour concerns such as 'not knowing how it would affect my baby if I have to take medications for COVID-19 (90.3%)' 'getting infected by COVID-19 during my pregnancy (89.7%)' 'not having a healthy pregnancy until birth (89%)'.

CONCLUSIONS

Delivery method preferences of pregnant women did not change in the COVID-19 pandemic. On the other hand, COVID-19 pandemic is impacting on the pregnant women experiencing moderate concerns about their pregnancy, delivery, postpartum period, and their baby.

Delivery outcomes in women with morbid obesity, where induction of labour was planned to prevent post-term complications

Morbid obesity and prolonged pregnancy are independently associated with adverse delivery and perinatal outcomes. We conducted a retrospective observational study on otherwise uncomplicated women with a body mass index (BMI) ≥ 40 kg/m² where, having reached term, induction of labour (IOL) was planned, to prevent prolonged pregnancy. The primary aim was to describe delivery outcomes and short-term maternal and perinatal adverse events. Of 117 cases included, 69 (59%) laboured spontaneously before the induction date, while 48 (41%) required an IOL. Of 48 patients that underwent an IOL, 22 (45.8%) achieved vaginal delivery, compared to 55 (79.7%) who laboured spontaneously (p = <.001). Twenty-two (18.8%) of the 117 babies weighed more than 4000 g, with 13 of these delivered vaginally. Overall, term patients with morbid obesity who laboured spontaneously before requiring induction, had a high rate of vaginal delivery. However, when IOL was required, the rate of caesarean delivery rose dramatically.Impact statementWhat is already known on this subject? Morbid obesity and prolonged pregnancy are independently associated with adverse delivery and perinatal outcomes. Induction of labour (IOL) increases the workload in busy units.What do the results of this study add? These results help inform accurate counselling on delivery outcomes, which is integral to respectful care, for the continuously increasing numbers of morbidly obese pregnant women.What the implications are of these findings for clinical practice and/or further research? It is preferable to avoid semi- or urgent caesarean deliveries in morbidly obese women after IOL. The outcomes of earlier induction of labour from 39- or 40-weeks' gestation requires investigation. Earlier induction may reduce the numbers of caesarean deliveries for abnormal cardiotocograph during the process.