A multi-centre quality improvement project to reduce the incidence of obstetric anal sphincter injury (OASI): study protocol

BACKGROUND

Third and fourth degree perineal tears, or obstetric anal sphincter injuries (OASI), sustained during childbirth can result in anal incontinence and psychosocial problems which require ongoing treatment. Within the English National Health System (NHS) reported rates of OASI have gradually increased. In response, a care bundle was developed incorporating four elements: 1) antenatal information to women, 2) manual perineal protection during all vaginal births, 3) episiotomy to be performed with a 60° mediolateral angle at crowning (when clinically indicated) and 4) perineal examination (including per rectum) after childbirth. Implementation of the OASI Care Bundle is aided by a skills development module and an awareness campaign. The project is a collaboration between two national professional bodies, an NHS hospital trust and an academic institution.

METHODS

Implementation of the OASI Care Bundle will be evaluated using a stepped-wedge design. From January 2017 sixteen maternity units across England, Wales and Scotland will participate in the study over a 15-month period, with sequential roll-out of the intervention in four blocks (regions) of four units. The primary clinical outcome is OASI rate. Regression analysis will adjust for differences in organisational characteristics and obstetric risk factors in women who gave birth before and after implementation of the care bundle. Focus group discussions and in-depth interviews with clinicians will evaluate the feasibility of integrating the care bundle into routine practice. Interviews with women will explore the acceptability of the intervention.

DISCUSSION

This protocol outlines the evaluation of our quality improvement project which aims to prevent OASI using a bundle of evidence-based interventions that are each widely used in practice. The OASI project aims to 1) standardise practice to prevent OASI in a way that is acceptable to clinicians and women and 2) identify the barriers and enablers associated with upscaling interventions within maternity units. If found to be effective, feasible and acceptable, the OASI Care Bundle will be shared with a range of audiences using the communication channels available to the professional bodies.

TRIAL REGISTRATION

The OASI Project was retrospectively registered on the ISCTRN12143325 database date assigned 03/10/2017.

Comparison of the effect of breast pump stimulation and oxytocin administration on the length of the third stage of labor, postpartum hemorrhage, and anemia: a randomized controlled trial

BACKGROUND

This study aimed to compare the effect of breast pump stimulation with that of oxytocin administration regarding the duration of the third stage of labor, postpartum hemorrhage, and anemia after delivery.

METHODS

In this study, 108 women were randomly assigned to two groups of breast pump stimulation (n = 54) and oxytocin administration (n = 54). Women in the breast stimulation group received breast pump stimulation (10 min intermittently for each breast with a negative pressure of 250 mmHg), while the women in the oxytocin (control) group received an infusion of 30 IU oxytocin in 1000 mL of Ringer's serum with a maximum rate of 10 mL infusion per min after delivery. The duration of the third stage of labor, blood loss during the third stage of labor and 24 h after delivery, hemoglobin and hematocrit (before and 24 h after delivery), after-birth pain, and the number of breastfeedings during the 24 h after delivery were recorded. The data were analyzed using the chi-square test, independent t-test, and Wilcoxon test.

RESULTS

The mean duration of the third stage was 5 ± 1.97 and 5.4 ± 2.5 min in the breast stimulation and women that received intravenous oxytocin respectively (p = 0.75). Most participants had mild postpartum hemorrhage (98.1 and 96.2% in the breast stimulation and women that received intravenous oxytocin, respectively, p = 0.99). Although hemoglobin and hematocrit levels significantly decreased in both groups 24 h after delivery, there was no significant difference between both groups regarding both parameters. After-birth pain was significantly lower and the number of breastfeeding during the 24 h after delivery was significantly more in the breast stimulation group compared to the control group.

CONCLUSIONS

Our results demonstrated no differences between breast pump stimulation and oxytocin administration regarding the duration of the third stage of labor, postpartum hemorrhage, anaemia, after-birth pain, and the number of breastfeedings during the 24 h after delivery.

TRIAL REGISTRATION NUMBER

The study protocol was registered in the Iranian Randomized Controlled Trial Registry (Ref. No.: IRCT2015050722146N1 ; Registration date: 2015-11-04). The study was registered prospectively and the enrollment date was 23/8/2015.

Obstetric fistula policy in Nigeria: a critical discourse analysis

BACKGROUND

In 2012, Nigeria's Federal Ministry of Health published its National Strategic Framework for the Elimination of Obstetric Fistula (NSFEOF), 2011-2015. The framework has since lapsed and there is no tangible evidence that the goal of eliminating obstetric fistula was met. To further inform future policy directions on obstetric fistula in Nigeria, this paper explores how the NSFEOF conceptualized obstetric fistula and its related issues, including child marriage and early childbearing.

METHODS

A critical discourse analysis of the policy was performed. We examined four policies in addition to the strategic framework: the Nigerian constitution; the Marriage Act; the Matrimonial Causes Act; and the National Reproductive Health Policy. We used the three phases of critical discourse analysis: textual analysis, analysis of discourse practice, and analysis of discursive events as instances of sociocultural practice.

RESULTS

The analysis demonstrates that, despite its title, the policy document focuses on reduction rather than elimination of obstetric fistula. The overall orientation of the policy is downstream, with minimal focus on prevention. The policy language suggests victim blaming. Furthermore, the extent to which subnational stakeholders in government and civil society were engaged in decision-making process for developing this policy is ambiguous. Although the policy is ostensibly based on principles of social justice and equity, several rhetorical positions suggest that the Nigerian constitutional environment and justice systems make no real provisions to protect the reproductive rights of girls in accordance with the United Nations' "2030 Agenda for Sustainable Development."

CONCLUSION

This analysis establishes that the Nigerian constitution, justice environment and the obstetric fistula policy itself do not demonstrate clear commitment to eradicating obstetric fistula. Specifically, a clear commitment to eradicating obstetric fistula would see the constitution and Marriage Act of Nigeria specify an age of consent that is consistent with the agenda to prevent obstetric fistula. Additionally, a policy to end obstetric fistulas in Nigeria must purposefully address the factors creating barrier to women's access to quality maternal healthcare services. Future policies and programs to eliminate obstetric fistulas should include perspectives of nurses, midwives, researchers and, women's interest groups.

Enhancing recognition of obstetric anal sphincter injuries in six maternity units in Palestine: an interventional quality improvement study

OBJECTIVE

To explore the impact of a training intervention on obstetric anal sphincter injuries' (OASIS) detection rate.

DESIGN

Prospective quality improvement interventional study.

SETTING

Six secondary and tertiary maternity units in Palestine.

POPULATION

Women having singleton vaginal births ≥23 weeks' gestation or babies weighing ≥500 g (n=22 922). Caesarean births (n=5431), multiple gestations (n=443) and vaginal births of unregistered perineum status (n=800) were excluded.

INTERVENTIONS

Training programme for enhancing OASIS detection was conducted between 31 January and 31 December 2015. International experts delivered 2-day standardisation workshop teaching OASIS diagnosis and repair to each maternity unit. They also provided additional training to three research fellows employed in three of the maternity units. This was followed by 13-week period of data collection (phase 1). Research fellows then delivered training intervention over 15-week interval (phase 2), including theoretical teaching and 'onsite' training in perineal trauma assessment within the six maternity units. Finally, 13-week postintervention observation (phase 3) followed.

PRIMARY OUTCOME MEASURE

OASIS rates were used as surrogate for OASIS recognition. OASIS rates were compared between different phases and between the two maternity unit groups (research fellow and non-research fellow based) using Pearson's χ² test.

RESULTS

A total 22 922 women were included. Among primiparous women, OASIS rate was higher in phase 2 (2.8%, p<0.001) and phase 3 (3.1%, p<0.001) than phase 1 (0.5%). However, no significant differences were detected in the rates of severe OASIS (third-degree 3c and fourth-degree tears) between phase 1 and 2 (0.5% vs 0.3%), because this would have required at least 103 women with severe OASIS to be included in each phase. Among parous women, OASIS rate was significantly higher in phase 2 (0.6%, p=0.002) but not in phase 3 (0.4%, p=0.071) compared with phase 1 (0.2%). Research fellows' maternity units showed higher OASIS rates among primiparous women in phase 2 (3.6% vs 1.4%, p=0.001) and phase 3 (4.3% vs 0.8%, p<0.001) than non-research fellows' maternity units.

CONCLUSIONS

This work is basically an epidemiological study which has identified the prevalence of perineal lacerations and their severity on a large sample of women representative of an entire geographical ethnic region. The quality improvement intervention improved OASIS detection mainly in the research fellows' maternity units. Regular mandatory national programmes in obstetric perineal trauma assessment and management by local champions are essential to mitigate the risk of missing significant degrees of trauma.

[PERINEAL TEARS THAT INVOLVE THE ANAL SPHINCTER - IS IT AN UNPREVENTABLE OBSTETRIC PROBLEM AND WHAT ARE ITS REPRECUSSIONS?]

Perineal tears that involve the anal sphincter, especially those which are occult, are common in cases of vaginal delivery or instrumental deliveries. Parturients who experience such types of perineal tears may suffer from flatus or fecal incontinence and also fistula to various surrounding organs. There is no consensus in the relevant medical literature regarding the risk factors for the development of these tears, as contradictive results are presented in various relevant studies. Traditional methods for perineal protection, executed by midwives, such as perineal massage with oil, have also failed to be proven as an effective measure for that purpose. The only theme on which there appears to be a consensus is the fact that protective episiotomy is not helpful in protecting the perineum during vaginal delivery. The inability to predict which parturient will have a perineal tear that involves the anal sphincter, as well as the lack of predictive measures to avoid their occurrence, drive more and more women to demand and receive cesarean section by maternal request, which is accepted by most obstetricians nowadays.

Prospective evaluation of the safety and feasibility of a pelvic floor dilator during active labor

INTRODUCTION AND HYPOTHESIS

The objective was to assess the safety and feasibility of using a pelvic floor dilator during active labor to prevent injuries to the levator ani muscle (LAM) and perineum.

METHODS

In a prospective pilot study, a pelvic floor dilator using soft pads was introduced into the vaginal canal to gradually expand the vagina, in 30 nulliparous women and in 10 controls. The primary outcomes were adverse events related to the device. Secondary outcomes were perineal lacerations after delivery, sonographically defined levator ani injury, hiatal area dimensions, and anal sphincter disruption, all at 12-20 weeks postpartum, and maximum pelvic floor dilation, time to achieve maximum dilation, and device retention rate.

RESULTS

From October 2014 through November 2016, a total of 494 women were screened, and 61 consented to the study. Thirty women used the device and 27 returned for follow-up. No maternal or neonatal injuries were related to use of the dilator. The average maximum dilation of the vaginal canal was 7.4 cm (SD 0.7, range 5.5-8.0). Dilation time averaged 27 min (SD 13, range 5-60). Device insertion adjustment was needed in 13 out of 30 cases (43%). Similar rates of 3th-4th degree perineal lacerations were seen in both groups. Levator ani avulsion was diagnosed in 2 out of 27 (7%) in the device group and in 1 out of 9 (11%) in the control group (p = 0.2). The rate of partial injury in the device group was 2 out of 27 (7%) vs 2 out of 9 (22%) in the comparison group (p = 0.2).

CONCLUSION

The use of the pelvic floor dilator during active labor is feasible. No safety issues were identified.

Clinical interventions to reduce stillbirths in sub-Saharan Africa: a mathematical model to estimate the potential reduction of stillbirths associated with specific obstetric conditions

OBJECTIVE

Stillbirths are among the most common adverse pregnancy outcomes, with 98% occurring in low-income countries. More than one-third occur in sub-Saharan Africa (SSA). However, the medical conditions causing stillbirths and interventions to reduce stillbirths from these conditions are not well documented. We estimated the reductions in stillbirths possible with combinations of interventions.

DESIGN

We developed a computerised model to estimate the impact of various interventions on stillbirths caused by the most common conditions. The model considered the location of obstetric care (home, clinic or hospital) and each intervention's efficacy, penetration and utilisation. Maternal transfers were also considered.

SETTING AND POPULATION

Pregnancies in SSA in 2012.

METHODS

For each condition, we created a series of scenarios involving different combinations of interventions and modelled their impact on stillbirth rates.

MAIN OUTCOME MEASURES

Stillbirths associated with various maternal and fetal conditions and the percentage reduction with various interventions.

RESULTS

Eight to ten maternal and fetal conditions were responsible for most stillbirths, but none for more than 15%. The most common conditions causing stillbirths in SSA include obstructed labour and uterine rupture, fetal distress and umbilical cord complications, fetal growth restriction, pre-eclampsia/eclampsia, and placental abruption/placenta praevia. Syphilis and malaria contribute smaller numbers. Reducing stillbirths requires appropriate diagnosis and management of each condition, usually including hospital care for monitoring and delivery, often by caesarean section. Maternal syphilis and malaria were the only conditions for which outpatient management alone reduced stillbirth.

CONCLUSIONS

Most stillbirths in low-income countries occur at term and during labour and therefore are preventable by appropriate obstetric care. Management focused on the maternal and fetal conditions that cause stillbirths is necessary to achieve stillbirth rates approaching those found in high-income countries.

TWEETABLE ABSTRACT

Reducing stillbirth incidence requires appropriate management of each causative condition and often caesarean delivery.

Upright versus lying down position in second stage of labour in nulliparous women with low dose epidural: BUMPES randomised controlled trial

Objective To determine whether being upright in the second stage of labour in nulliparous women with a low dose epidural increases the chance of spontaneous vaginal birth compared with lying down.Design Multicentre pragmatic individually randomised controlled trial.Setting 41 UK hospital labour wards.Participants 3093 nulliparous women aged 16 or older, at term with a singleton cephalic presentation and in the second stage of labour with epidural analgesia.Interventions Women were allocated to an upright or lying down position, using a secure web based randomisation service, stratified by centre, with no masking of participants or clinicians to the trial interventions.Main outcome measures The primary outcome was spontaneous vaginal birth. Women were analysed in the groups into which they were randomly allocated, regardless of position recorded at any time during the second stage of labour (excluding women with no valid consent, who withdrew, or who did not reach second stage before delivery). Secondary outcomes included mode of birth, perineal trauma, infant Apgar score <4 at five minutes, admission to a neonatal unit, and longer term included maternal physical and psychological health, incontinence, and infant gross developmental delay. Results Between 4 October 2010 and 31 January 2014, 3236 women were randomised and 3093 (95.6%) included in the primary analysis (1556 in the upright group and 1537 in the lying down group). Significantly fewer spontaneous vaginal births occurred in women in the upright group: 35.2% (548/1556) compared with 41.1% (632/1537) in the lying down group (adjusted risk ratio 0.86, 95% confidence interval 0.78 to 0.94). This represents a 5.9% absolute increase in the chance of spontaneous vaginal birth in the lying down group (number needed to treat 17, 95% confidence interval 11 to 40). No evidence of differences was found for most of the secondary maternal, neonatal, or longer term outcomes including instrumental vaginal delivery (adjusted risk ratio 1.08, 99% confidence interval 0.99 to 1.18), obstetric anal sphincter injury (1.27, 0.88 to 1.84), infant Apgar score <4 at five minutes (0.66, 0.06 to 6.88), and maternal faecal incontinence at one year (1.18, 0.61 to 2.28).Conclusions Evidence shows that lying down in the second stage of labour results in more spontaneous vaginal births in nulliparous women with epidural analgesia, with no apparent disadvantages in relation to short or longer term outcomes for mother or baby.Trial registration Current Controlled Trials ISRCTN35706297.

Perineal techniques during the second stage of labour for reducing perineal trauma

BACKGROUND

Most vaginal births are associated with trauma to the genital tract. The morbidity associated with perineal trauma can be significant, especially when it comes to third- and fourth-degree tears. Different interventions including perineal massage, warm or cold compresses, and perineal management techniques have been used to prevent trauma. This is an update of a Cochrane review that was first published in 2011.

OBJECTIVES

To assess the effect of perineal techniques during the second stage of labour on the incidence and morbidity associated with perineal trauma.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (26 September 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Published and unpublished randomised and quasi-randomised controlled trials evaluating perineal techniques during the second stage of labour. Cross-over trials were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion, extracted data and evaluated methodological quality. We checked data for accuracy.

MAIN RESULTS

Twenty-two trials were eligible for inclusion (with 20 trials involving 15,181 women providing data). Overall, trials were at moderate to high risk of bias; none had adequate blinding, and most were unclear for both allocation concealment and incomplete outcome data. Interventions compared included the use of perineal massage, warm and cold compresses, and other perineal management techniques.Most studies did not report data on our secondary outcomes. We downgraded evidence for risk of bias, inconsistency, and imprecision for all comparisons. Hands off (or poised) compared to hands onHands on or hands off the perineum made no clear difference in incidence of intact perineum (average risk ratio (RR) 1.03, 95% confidence interval (CI) 0.95 to 1.12, two studies, Tau² 0.00, I² 37%, 6547 women; moderate-quality evidence), first-degree perineal tears (average RR 1.32, 95% CI 0.99 to 1.77, two studies, 700 women; low-quality evidence), second-degree tears (average RR 0.77, 95% CI 0.47 to 1.28, two studies, 700 women; low-quality evidence), or third- or fourth-degree tears (average RR 0.68, 95% CI 0.21 to 2.26, five studies, Tau² 0.92, I² 72%, 7317 women; very low-quality evidence). Substantial heterogeneity for third- or fourth-degree tears means these data should be interpreted with caution. Episiotomy was more frequent in the hands-on group (average RR 0.58, 95% CI 0.43 to 0.79, Tau² 0.07, I² 74%, four studies, 7247 women; low-quality evidence), but there was considerable heterogeneity between the four included studies.There were no data for perineal trauma requiring suturing. Warm compresses versus control (hands off or no warm compress)A warm compress did not have any clear effect on the incidence of intact perineum (average RR 1.02, 95% CI 0.85 to 1.21; 1799 women; four studies; moderate-quality evidence), perineal trauma requiring suturing (average RR 1.14, 95% CI 0.79 to 1.66; 76 women; one study; very low-quality evidence), second-degree tears (average RR 0.95, 95% CI 0.58 to 1.56; 274 women; two studies; very low-quality evidence), or episiotomy (average RR 0.86, 95% CI 0.60 to 1.23; 1799 women; four studies; low-quality evidence). It is uncertain whether warm compress increases or reduces the incidence of first-degree tears (average RR 1.19, 95% CI 0.38 to 3.79; 274 women; two studies; I² 88%; very low-quality evidence).Fewer third- or fourth-degree perineal tears were reported in the warm-compress group (average RR 0.46, 95% CI 0.27 to 0.79; 1799 women; four studies; moderate-quality evidence). Massage versus control (hands off or routine care)The incidence of intact perineum was increased in the perineal-massage group (average RR 1.74, 95% CI 1.11 to 2.73, six studies, 2618 women; I² 83% low-quality evidence) but there was substantial heterogeneity between studies). This group experienced fewer third- or fourth-degree tears (average RR 0.49, 95% CI 0.25 to 0.94, five studies, 2477 women; moderate-quality evidence).There were no clear differences between groups for perineal trauma requiring suturing (average RR 1.10, 95% CI 0.75 to 1.61, one study, 76 women; very low-quality evidence), first-degree tears (average RR 1.55, 95% CI 0.79 to 3.05, five studies, Tau² 0.47, I² 85%, 537 women; very low-quality evidence), or second-degree tears (average RR 1.08, 95% CI 0.55 to 2.12, five studies, Tau² 0.32, I² 62%, 537 women; very low-quality evidence). Perineal massage may reduce episiotomy although there was considerable uncertainty around the effect estimate (average RR 0.55, 95% CI 0.29 to 1.03, seven studies, Tau² 0.43, I² 92%, 2684 women; very low-quality evidence). Heterogeneity was high for first-degree tear, second-degree tear and for episiotomy - these data should be interpreted with caution. Ritgen's manoeuvre versus standard careOne study (66 women) found that women receiving Ritgen's manoeuvre were less likely to have a first-degree tear (RR 0.32, 95% CI 0.14 to 0.69; very low-quality evidence), more likely to have a second-degree tear (RR 3.25, 95% CI 1.73 to 6.09; very low-quality evidence), and neither more nor less likely to have an intact perineum (RR 0.17, 95% CI 0.02 to 1.31; very low-quality evidence). One larger study reported that Ritgen's manoeuvre did not have an effect on incidence of third- or fourth-degree tears (RR 1.24, 95% CI 0.78 to 1.96,1423 women; low-quality evidence). Episiotomy was not clearly different between groups (RR 0.81, 95% CI 0.63 to 1.03, two studies, 1489 women; low-quality evidence). Other comparisonsThe delivery of posterior versus anterior shoulder first, use of a perineal protection device, different oils/wax, and cold compresses did not show any effects on perineal outcomes. Only one study contributed to each of these comparisons, so data were insufficient to draw conclusions.

AUTHORS' CONCLUSIONS

Moderate-quality evidence suggests that warm compresses, and massage, may reduce third- and fourth-degree tears but the impact of these techniques on other outcomes was unclear or inconsistent. Poor-quality evidence suggests hands-off techniques may reduce episiotomy, but this technique had no clear impact on other outcomes. There were insufficient data to show whether other perineal techniques result in improved outcomes.Further research could be performed evaluating perineal techniques, warm compresses and massage, and how different types of oil used during massage affect women and their babies. It is important for any future research to collect information on women's views.

Obstetric anal sphincter injuries and the role of the midwife

Obstetric anal sphincter injuries (OASIS) can have a very negative impact on women's health and quality of life. Literature exists concerning the role of the surgeon and physiotherapist after OASIS, but there is a dearth of literature pertaining to the role of the midwife in the management of women following an obstetric anal sphincter injury. This article examines the midwife's role and describes a new service instituted at Hadassah-Hebrew University medical centre, Jerusalem, utilised in the early postpartum period while the woman is still in hospital, entitled Special Services for Perineal Trauma.

What Do Obstetricians Really Think about Ultrasound in the Delivery Room?

BACKGROUND

In recent years, the role of intrapartum sonography has expanded in childbirth management, in subjective clinical situations such as arrested deliveries, or prior to instrumental deliveries.

OBJECTIVES

To assess the current use of intrapartum ultrasound by obstetricians in Israel.

METHODS

An anonymous questionnaire was completed by 79 obstetricians in second- and third level- hospitals in Israel. The results were analyzed according to main subspecialty (sonography, delivery), experience and gender.

RESULTS

A questionnaire was completed by 56 senior obstetricians and 23 interns with an average experience of 14.3 and 2.4 years, respectively. All obstetricians performed ultrasound examinations in the delivery room for basic indications such as fetal presentation during twin delivery and to rule out placenta previa. Sonographers consistently reported advanced indications as compared to senior members of delivery teams and interns in the assessment of prolonged first (52% vs. 14% vs. 14%) and second stage of labor (88% vs. 52% vs. 62%) and in assessment of fetal head station (60% vs. 30% vs. 22%), head progression during descent (48% vs. 23% vs. 11%), diagnosis of head position (88% vs. 68% vs. 60%), spine direction (92% vs. 59% vs. 53%) and asynclytism (41% vs. 20% vs. 29%).

CONCLUSIONS

Ultrasound is currently used by all physicians in the delivery room for basic indications. However, obstetric teams report a low use of advanced intrapartum ultrasound and prefer to rely on their clinical experience. Advanced intrapartum sonographic imaging should be an integral part of obstetric qualifications. A steep learning curve, along with high reproducibility, suggests that ultrasound devices will become a common tool in labor and delivery management.

The fundamental skills: reducing maternal morbidity and mortality

The accurate assessment of basic observations such as blood pressure, heart rate, arterial oxygen saturation of blood (SpO²), respirations, temperature and level of consciousness (AVPU score) underpin the fundamentals of basic midwifery care provision. However, after identifying that the signs of impending maternal collapse often went unrecognised leading to subsequent morbidities and mortalities, the confidential enquiry into maternal and child health (CEMACH) report in 2007 (Lewis 2007) recommended that all obstetric women's observations were recorded through a modified early obstetric warning system (MEOWS). This allows for the early detection of women who may become critically unwell and provides an opportunity for practitioners to act promptly and prevent deterioration (Knight et al 2016).This article provides an overview of the MEOWS scores as a tool to improve maternal morbidity and mortality within maternity care.

Pregnancies with factor V deficiency: a case report and review of the literature

CASE REPORT

A 30-year-old Japanese nulliparous woman visited for pregnancy at 33 weeks with a massive ovarian tumor located in the pouch of Douglas. By preoperative screening, her prothrombin time (PT) and activated partial thromboplastin time (APTT) were prolonged, and her FV activity was significantly decreased to 4.8%. After prophylactic FFP 20 ml/kg was administered and her FV factor was 19.3%, cesarean delivery was performed, and her perioperative course was uneventful. One year later, she underwent a dilatation and evacuation because of a missed abortion, although prophylactic FFP was not administered. During a third pregnancy, after prophylactic FFP 20 ml/kg was administered and FV activity increased to 21.1%, elective cesarean delivery was performed, and her postoperative course was uneventful.

CONCLUSION

For surgical therapy or delivery, the goal of therapy is to maintain FV activity above 20%. It is particularly useful to administer prophylactic FFP.

Effect of the type of maternal pushing during the second stage of labour on obstetric and neonatal outcome: a multicentre randomised trial-the EOLE study protocol

INTRODUCTION

The scientific data currently available do not allow any definitive conclusion to be reached about what type of pushing should be recommended to women during the second stage of labour. The objective of this trial is to assess and compare the effectiveness of directed open-glottis pushing versus directed closed-glottis pushing. Secondary objectives are to assess, according to the type of pushing: immediate maternal and neonatal morbidity, intermediate-term maternal pelvic floor morbidity, uncomplicated birth, and women's satisfaction at 4 weeks post partum.

METHODS AND ANALYSIS

This multicentre randomised clinical trial compares directed closed-glottis pushing (Valsalva) versus directed open-glottis pushing during the second stage of labour in 4 hospitals of France. The study population includes pregnant women who received instruction in both types of pushing, have no previous caesarean delivery, are at term and have a vaginal delivery planned. Randomisation takes place during labour once cervical dilation ≥7 cm. The principal end point is assessed by a composite criterion: spontaneous delivery without perineal lesion (no episiotomy or spontaneous second-degree, third-degree or fourth-degree lacerations). We will need to recruit 125 women per group. The primary analysis will be by intention-to-treat analysis, with the principal results reported as crude relative risks (RRs) with their 95% CIs. A multivariate analysis will be performed to take prognostic and confounding factors into account to obtain adjusted RRs.

ETHICS AND DISSEMINATION

This study was approved by a French Institutional Review Board (Comité de Protection des Personnes Sud Est 6:N°AU1168). Results will be reported in peer-reviewed journals and at scientific meetings. This study will make it possible to assess the effectiveness of 2 types of directed pushing used in French practice and to assess their potential maternal, fetal and neonatal effects. Findings from the study will be useful for counselling pregnant women before and during labour.

TRIAL REGISTRATION NUMBER

Agence national de sécurité du médicament et des produits de santé (ANSM): 150099B-22 and IDRCB: 2014-A01920-47. ClinicalTrials.gov: NCT02474745. Pre-result stage.

Male Involvement and Accommodation During Obstetric Emergencies in Rural Ghana: A Qualitative Analysis

CONTEXT

Although men potentially play an important role in emergency obstetric care in Sub-Saharan Africa, few studies have examined the ways in which men are involved in such emergencies, the consequences of their involvement or the degree to which health facilities accommodate men.

METHODS

Qualitative interviews were conducted with 39 mothers and fathers in two districts in Northern and Central Ghana who had experienced obstetric emergencies, such as severe birth complications, to obtain narratives about those experiences. In addition, interviews with six health facility workers and eight focus group discussions with community members were conducted. Transcripts were analyzed using an inductive analytic approach.

RESULTS

Although some men had not been involved at all during their partner's obstetric emergency, two-thirds had provided some combination of financial, emotional and instrumental support. On the other hand, several men had acted as gatekeepers, and their control of resources and decisions had resulted in care-seeking delays. Although many respondents reported that health facilities accommodated male partners (e.g., by providing an appropriate space for men during delivery), others found that facilities were not accommodating, in some cases ignoring or disrespecting men. A few respondents had encountered improper staff expectations, notably that men would accompany their partner to the facility, a requirement that limits women's autonomy and delays care.

CONCLUSIONS

Policies and programs should promote supportive behavior by men during obstetric emergencies while empowering women. Health facility policies regarding accommodation of men during obstetric emergencies need to consider women's and men's preferences. Research should examine whether particular forms of support improve maternal and newborn health outcomes.

Good practices according to WHO's recommendation for normal labor and birth and women's assessment of the care received: the "birth in Brazil" national research study, 2011/2012

BACKGROUND

The World Health Organization recommends good practices for the conduct of uncomplicated labor and birth, with the aim of improving the quality of and assessment by women of childbirth care. The aim of this study was to evaluate the association between adoption of good practices according to WHO's recommendation for normal labor and birth and assessment by women of the care received.

METHODS

Birth in Brazil is a national hospital-based study with countrywide representation consisting of 23,894 mothers and their newborns, conducted between February 2011 and October 2012. The present study analysed a subsample of this national survey. Postpartum women classified as low risk during pregnancy who had experienced either spontaneous or induced labor were included in this study, totalling 4102 mothers. To estimate the association between assessment by women of the childbirth care received (dependent variable) and good practices according to WHO's recommendation during normal labor and birth (independent variables), a multinomial logistic regression analysis was used and crude and adjusted odds ratios calculated with their 95 % confidence intervals.

RESULTS

The good practices associated with positive assessment of the care received by women during labor and birth included the partner's presence, privacy in the birthing place, time available to ask questions, clarity of information received, and empathic support from caregivers during labor and birth. Freedom of movement, free nutrition offered, choice of companions, nonpharmacological analgesia, skin-to-skin contact and breastfeeding in the childbirth room were not associated with the assessment by women of the care received.

CONCLUSIONS

Our findings reveal the importance to mothers of their relationship with the team of caregivers during labor and birth. Therefore, caregiver teams must be qualified within a more humanistic vision of childbirth health care.

Episiotomy and obstetric outcomes among women living with type 3 female genital mutilation: a secondary analysis

BACKGROUND

To investigate the association between type of episiotomy and obstetric outcomes among 6,187 women with type 3 Female Genital Mutilation (FGM).

METHODS

We conducted a secondary analysis of women presenting in labor to 28 obstetric centres in Burkina Faso, Ghana, Kenya, Nigeria, Senegal and Sudan between November 2001 and March 2003. Data were analysed using cross tabulations and multivariable logistic regression to determine if type of episiotomy by FGM classification had a significant impact on key maternal outcomes. Our main outcome measures were anal sphincter tears, intrapartum blood loss requiring an intervention, and postpartum haemorrhage.

RESULTS

Type of episiotomy performed varied significantly by FGM status. Among women without FGM, the most common type of episiotomy performed was posterior lateral (25.4 %). The prevalence of the most extensive type of episiotomy, anterior and posterior lateral episiotomy increased with type of FGM. Among women without FGM, 0.4 % had this type of episiotomy. This increased to 0.6 % for women with FGM Types 1, 2 or 4 and to 54.6 % of all women delivering vaginally with FGM Type 3. After adjustment, women with an anterior episiotomy, (AOR = 0.15 95 %; CI 0.06-0.40); posterior lateral episiotomy (AOR = 0.68 95 %; CI 0.50-0.94) or both anterior and posterior lateral episiotomies performed concurrently (AOR = 0.21 95 % CI 0.12-0.36) were all significantly less likely to have anal sphincter tears compared to women without episiotomies. Women with anterior episiotomy (AOR = 0.08; 95%CI 0.02-0.24), posterior lateral episiotomy (AOR = 0.17 95 %; CI 0.05-0.52) and the combination of the two (AOR = 0.04 95 % CI 0.01-0.11) were significantly less likely to have postpartum haemorrhage compared with women who had no episiotomy.

CONCLUSIONS

Among women living with FGM Type 3, episiotomies were protective against anal sphincter tears and postpartum haemorrhage. Further clinical and research is needed to guide clinical practice of when episiotomies should be performed.

Referrals between Public Sector Health Institutions for Women with Obstetric High Risk, Complications, or Emergencies in India - A Systematic Review

Emergency obstetric care (EmOC) within primary health care systems requires a linked referral system to be effective in reducing maternal death. This systematic review aimed to summarize evidence on the proportion of referrals between institutions during pregnancy and delivery, and the factors affecting referrals, in India. We searched 6 electronic databases, reviewed four regional databases and repositories, and relevant program reports from India published between 1994 and 2013. All types of study or reports (except editorials, comments and letters) which reported on institution-referrals (out-referral or in-referral) for obstetric care were included. Results were synthesized on the proportion and the reasons for referral, and factors affecting referrals. Of the 11,346 articles identified by the search, we included 232 articles in the full text review and extracted data from 16 studies that met our inclusion criteria Of the 16, one was RCT, seven intervention cohort (without controls), six cross-sectional, and three qualitative studies. Bias and quality of studies were reported. Between 25% and 52% of all pregnancies were referred from Sub-centres for antenatal high-risk, 14% to 36% from nurse run delivery or basic EmOC centres for complications or emergencies, and 2 to 7% were referred from doctor run basic EmOC centres for specialist care at comprehensive EmOC centres. Problems identified with referrals from peripheral health centres included low skills and confidence of staff, reluctance to induce labour, confusion over the clinical criteria for referral, non-uniform standards of care at referral institutions, a tendency to by-pass middle level institutions, a lack of referral communication and supervision, and poor compliance. The high proportion of referrals from peripheral health centers reflects the lack of appropriate clinical guidelines, processes, and skills for obstetric care and referral in India. This, combined with inadequate referral communication and low compliance, is likely to contribute to gaps and delays in the provision of emergency obstetric care.

Patient Safety Implications of Electronic Alerts and Alarms of Maternal - Fetal Status During Labor

When nurses care for women during labor, they encounter numerous alerts and alarms from electronic fetal monitors and their surveillance systems. Notifications of values of physiologic parameters for a woman and fetus that may be outside preset limits are generated via visual and audible cues. There is no standardization of these alert and alarm parameters among electronic fetal monitoring vendors in the United States, and there are no data supporting their sensitivity and specificity. Agreement among professional organizations about physiologic parameters for alerts and alarms commonly used during labor is lacking. It is unknown if labor nurses view the alerts and alarms as helpful or a nuisance. There is no evidence that they promote or hinder patient safety. This clinical issue warrants our attention as labor nurses.

Babies who die from labour-related intrapartum hypoxia: a confidential enquiry in South African public hospitals

Seventeen hospitals, from a range of health-care environments, participated in confidential enquiries of perinatal deaths resulting from labour-related intrapartum hypoxia. There were 102 deaths, including 22 stillbirths and 80 neonatal deaths. The mean birthweight was 3021 g. The active phase of the first stage of labour was prolonged beyond 12 h in six cases, and oxytocin was used for induction or augmentation in 10 women. Fetal heart decelerations were detected in 39 (49%) of the babies that went on to die in the neonatal period, and meconium passage was evident in 50 (63%). There were six breech presentations, and seven cases of cord prolapse. The majority of these deaths occurred in low-risk women with apparently uncomplicated labour. There appears to be a failure to detect or respond to evidence of fetal distress. Intrapartum care for all women in labour requires close attention to detail in monitoring fetal health.