Continuous support for women during childbirth

Effect of Continued Support of Midwifery Students in Labour on the Childbirth and Labour Consequences: A Randomized Controlled Clinical Trial

INTRODUCTION

Childbirth experience is a process throughout women's life and the most important consequence of labour. Support is the key factor to have a positive experience of childbirth. In order to improve and reduce the stress and anxiety levels in women during labour and cope with the childbirth pain, the emotional, physical and educational support of doulas can be used.

AIM

This study was aimed to evaluate the effect of continued support of midwifery students in labour on the childbirth and labour consequences.

MATERIALS AND METHODS

The present study was conducted using a randomized controlled clinical trial design on 100 pregnant women referred to the maternity ward at Fatemieh Hospital, Shahroud, Iran. The participants were assigned to the supportive or non-supportive group based on allocation sequence using a randomized block design and table of computer-generated random numbers prior to beginning the study. Supportive care was provided by the trained midwifery students. Childbirth and labour consequences were analysed by chi-square test, Fisher-exact test, independent t-test, Mann-Whitney U-test using SPSS-21 software.

RESULTS

The results showed a significantly lower duration of the first stage of labour in the supportive group, as compared to that in the non-supportive group (p <0.001). Moreover, Apgar scores in the supportive group, compared to those in the non-supportive group, significantly increased at minutes 1 and 5 (p <0.001 and p = 0.04, respectively).

CONCLUSION

The findings of this study showed that the supportive care provided by the midwifery students shortens duration of the first stage of labour and improves the Apgar scores in the first and fifth minutes.

Comparative study analysing women's childbirth satisfaction and obstetric outcomes across two different models of maternity care

OBJECTIVES

To describe the differences in obstetrical results and women's childbirth satisfaction across 2 different models of maternity care (biomedical model and humanised birth).

SETTING

2 university hospitals in south-eastern Spain from April to October 2013.

DESIGN

A correlational descriptive study.

PARTICIPANTS

A convenience sample of 406 women participated in the study, 204 of the biomedical model and 202 of the humanised model.

RESULTS

The differences in obstetrical results were (biomedical model/humanised model): onset of labour (spontaneous 66/137, augmentation 70/1, p=0.0005), pain relief (epidural 172/132, no pain relief 9/40, p=0.0005), mode of delivery (normal vaginal 140/165, instrumental 48/23, p=0.004), length of labour (0-4 hours 69/93, >4 hours 133/108, p=0.011), condition of perineum (intact perineum or tear 94/178, episiotomy 100/24, p=0.0005). The total questionnaire score (100) gave a mean (M) of 78.33 and SD of 8.46 in the biomedical model of care and an M of 82.01 and SD of 7.97 in the humanised model of care (p=0.0005). In the analysis of the results per items, statistical differences were found in 8 of the 9 subscales. The highest scores were reached in the humanised model of maternity care.

CONCLUSIONS

The humanised model of maternity care offers better obstetrical outcomes and women's satisfaction scores during the labour, birth and immediate postnatal period than does the biomedical model.

Expanding the evidence base for global recommendations on health systems: strengths and challenges of the OptimizeMNH guidance process

BACKGROUND

In 2012, the World Health Organization (WHO) published recommendations on the use of optimization or "task-shifting" strategies for key, effective maternal and newborn interventions (the OptimizeMNH guidance). When making recommendations about complex health system interventions such as task-shifting, information about the feasibility and acceptability of interventions can be as important as information about their effectiveness. However, these issues are usually not addressed with the same rigour. This paper describes our use of several innovative strategies to broaden the range of evidence used to develop the OptimizeMNH guidance. In this guidance, we systematically included evidence regarding the acceptability and feasibility of relevant task-shifting interventions, primarily using qualitative evidence syntheses and multi-country case study syntheses; we used an approach to assess confidence in findings from qualitative evidence syntheses (the Grading of Recommendations, Assessment, Development and Evaluation-Confidence in Evidence from Reviews of Qualitative Research (GRADE-CERQual) approach); we used a structured evidence-to-decision framework for health systems (the DECIDE framework) to help the guidance panel members move from the different types of evidence to recommendations.

RESULTS

The systematic inclusion of a broader range of evidence, and the use of new guideline development tools, had a number of impacts. Firstly, this broader range of evidence provided relevant information about the feasibility and acceptability of interventions considered in the guidance as well as information about key implementation considerations. However, inclusion of this evidence required more time, resources and skills. Secondly, the GRADE-CERQual approach provided a method for indicating to panel members how much confidence they should place in the findings from the qualitative evidence syntheses and so helped panel members to use this qualitative evidence appropriately. Thirdly, the DECIDE framework gave us a structured format in which we could present a large and complex body of evidence to panel members and end users. The framework also prompted the panel to justify their recommendations, giving end users a record of how these decisions were made.

CONCLUSIONS

By expanding the range of evidence assessed in a guideline process, we increase the amount of time and resources required. Nevertheless, the WHO has assessed the outputs of this process to be valuable and is currently repeating the approach used in OptimizeMNH in other guidance processes.

Midwives' attitudes towards supporting normal labour and birth - A cross-sectional study in South Germany

OBJECTIVE

supporting healthy and normal physiological birth is part of the global maternity care agenda. Rising rates of interventions have been attributed to several factors, including characteristics, attitudes and preferences of childbearing women and their care providers. In this paper, the application of a scale that measures midwives' attitudes towards supporting normal labour and birth is described as well as factors that are associated with favourable attitudes, such as general self-efficacy, years in midwifery practice, and primary practice setting.

DESIGN

in this cross-sectional study an online questionnaire was sent out via e-mail to midwives in two regions of South Germany. The questionnaire contained a validated general self-efficacy scale, a 38-item instrument that measures attitudes towards supporting normal birth among German midwives and questions about midwives' practice experiences and educational preparation.

FINDINGS

on average, participants (n=188) were 39 years old (SD=10.3), and had 12 years of experience caring for women during labour and birth (SD=9.6). Multivariate modelling revealed that higher general self-efficacy, working primarily in out-of-hospital settings and having provided intrapartum care for fewer years were significantly associated with midwives' favourable attitudes towards supporting physiological birth (variance explained R(2)=29.0%, n=184). General self-efficacy (1.4%) and years of work experience (3.3%) contributed less of the variance in the outcome than work setting (24.5%). Sources of knowledge about normal birth were not significantly associated with the outcome and reduced the overall variance explained by 0.2%.

CONCLUSIONS

the study has shown that, compared to work setting, the general self-efficacy of German midwives, years providing intrapartum care and sources of knowledge about normal birth had comparatively little impact on their attitude towards supporting normal physiologic birth. Increasing exposure to out-of-hospital birth among German midwives throughout education and practice and fostering the skills and confidence necessary to support normal birth in hospital settings are important strategies to decrease unnecessary obstetric interventions.

Understanding Factors That Influence Adolescent Mothers' Doula Use: A Qualitative Study

In this study, we examined factors that influenced doula use among adolescent mothers in a community-based childbirth education and doula program. We used a qualitative case study approach to gather perspectives from adolescent mothers and doulas through semistructured interviews, field observations, and a focus group. These women collectively revealed multiple themes related to doula use among adolescent mothers, including relationship development and barriers to doula use at the individual and structural levels. Effective training and support for doulas that serve adolescent clients can improve these mothers' birth experiences, and program planners in the United States and other countries can use process evaluations to improve doula programs for adolescent mothers.

The meaning of a very positive birth experience: focus groups discussions with women

BACKGROUND

The experience of giving birth has long-term implications for a woman's health and wellbeing. The birth experience and satisfaction with birth have been associated with several factors and emotional dimensions of care and been shown to influence women's overall assessment. Individualized emotional support has been shown to empower women and increase the possibility of a positive birth experience. How women assess their experience and the factors that contribute to a positive birth experience are of importance for midwives and other caregivers. The aim of this study was to describe women's experience of a very positive birth experience.

METHOD

The study followed a qualitative descriptive design. Twenty-six women participated in focus group discussions 6-7 years after a birth they had assessed as very positive. At the time of the birth, they had all taken part in a large prospective longitudinal cohort study performed in northern Sweden. In the present study, thematic analysis was used to review the transcribed data.

RESULTS

All women looked back very positively on their birth experience. Two themes and six sub-themes were identified that described the meaning of a very positive birth experience. Women related their experience to internal (e.g., their own ability and strength) and external (e.g., a trustful and respectful relationship with the midwife) factors. A woman's sense of trust and support from the father of the child was also important. The feeling of safety promoted by a supportive environment was essential for gaining control during birth and for focusing on techniques that enabled the women to manage labour.

CONCLUSION

It is an essential part of midwifery care to build relationships with women where mutual trust in one another's competence is paramount. The midwife is the active guide through pregnancy and birth and should express a strong belief in a woman's ability to give birth. Midwives are required to inform, encourage and to provide the tools to enable birth, making it important for midwives to invite the partner to be part of a team, in which everyone works together for the benefit of the woman and child.

Comparison of the Effects of Maternal Supportive Care and Acupressure (at BL32 Acupoint) on Labor Length and Infant's Apgar Score

BACKGROUND & OBJECTIVES

Prolonged labor leads to increase of cesarean deliveries, reduction of fetal heart rate, and maternal as well as infantile complications. Therefore, many women tend to use pharmacological or non-pharmacological methods for reduction of labor length. The present study aimed to compare the effects of maternal supportive care and acupressure (at BL32 acupoint) on labor length and infant's Apgar score.

METHODS

In this clinical trial, 150 women with low-risk pregnancy were randomly divided into supportive care, acupressure, and control groups each containing 50 subjects. The data were collected using a questionnaire including demographic and pregnancy characteristics. Then, the data were analyzed using Chi-square test and one-way ANOVA.

RESULTS

The mean length of the first and second stages of labor was respectively 157.0±29.5 and 58.9±5.8 minutes in the supportive care group, 161.7±37.3 and 56.1±31.4 minutes in the acupressure group, ad 281.0±9.8 and 128.4±44.9 minutes in the control group. The difference between the length of labor stages was significant in the three study groups (P<0.001). Moreover, the frequency of Apgar score>8 in the first and 5th minutes was higher in the supportive care and acupressure groups compared to the control group, and the difference was statistically significant (P<0.001).

CONCLUSION

Continuous support and acupressure could reduce the length of labor stages and increase the infants' Apgar scores. Therefore, these methods, as effective non-pharmacological strategies, can be introduced to the medical staff to improve the delivery outcomes.

Midwives' experiences of labour care in midwifery units. A qualitative interview study in a Norwegian setting

OBJECTIVE

In some economically developed countries, women's choice of birth care and birth place is encouraged. The aim of this study was to explore and describe the experiences of midwives who started working in alongside/free-standing midwifery units (AMU/FMU) and their experiences with labour care in this setting.

METHODS

A qualitative explorative design using a phenomenographic approach was used. Semi-structured interviews were conducted with ten strategically sampled midwives working in midwifery units.

RESULTS

The analysis revealed the following five categories of experiences noted by the midwives: mixed emotions and de-learning obstetric unit habits, revitalising midwifery philosophy, alertness and preparedness, presence and patience, and coping with time.

CONCLUSIONS

Starting to work in an AMU/FMU can be a distressing period for a midwife. First, it may require de-learning the medical approach to birth, and, second, it may entail a revitalisation (and re-learning) of birth care that promotes physiological birth. Midwifery, particularly in FMUs, requires an especially careful assessment of the labouring process, the ability to be foresighted, and capability in emergencies. The autonomy of midwives may be constrained also in AMUs/FMUs. However, working in these settings is also viewed as experiencing "the art of midwifery" and enables revitalisation of the midwifery philosophy.

Establishing a volunteer doula program within a nurse-midwifery education program: a winning situation for both clients and students

The use of labor doulas is beneficial for mothers and newborns, but availability and cost can be barriers. The Nashville Volunteer Doula Program was formed to provide labor support to clients of a faculty nurse-midwifery practice. The volunteer doula pool is comprised of both nurse-midwifery students who have trained as doulas and community doulas. Training and coordination of volunteers are managed by nurse-midwifery students with faculty support. Students gain valuable exposure to providing supportive care during labor and birth, which augments their nurse-midwifery education. This novel program operates at a low cost and offers benefits to students as well as women who use the doula service. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.

Status of respectful and non-abusive care during facility-based childbirth in a hospital and health centers in Addis Ababa, Ethiopia

Background

According to the 2011 Ethiopian Demographic and Health Survey, 90.1% of mothers do not deliver in health facilities, with 29.5% citing non-customary service as causative. A low level of skilled attendance at birth is among the leading causes of maternal mortality in low - and middle-income countries.

Methods

A cross-sectional study was undertaken in four health facilities (one specialized teaching hospital and its three catchment health centers) in Addis Ababa, Ethiopia, to quantitatively determine the level and types of disrespect and abuse faced by women during facility-based childbirth, along with their subjective experiences of disrespect and abuse. A questionnaire was administered to 173 mothers immediately prior to discharge from their respective health facility. Reported disrespect and abuse during childbirth was measured under seven categories using 23 performance indicators.

Results

Among multigravida mothers (n = 103), 71.8% had a history of a previous institutional birth and 78% (75.3% in health centers and 81.8% in hospital; p = 0.295) of respondents experienced one or more categories of disrespect and abuse. The violation of the right to information, informed consent, and choice/preference of position during childbirth was reported by all women who gave birth in the hospital and 89.4% of respondents in health centers. Mothers were left without attention during labor in 39.3% of cases (14.1% in health centers and 63.6% in hospital; p < 0.001). Although 78.6% (n = 136) of respondents objectively faced disrespect and abuse, only 22 (16.2%) subjectively experienced disrespect and abuse.

Conclusions

This quantitative study reveals a high level of disrespect and abuse during childbirth that was not perceived as such by the majority of respondents. It is every woman’s right to give birth in woman-centered environment free from disrespect and abuse. Understanding how women define abuse is crucial if Ethiopia is to succeed in increasing the uptake of facility-based births.

Social inequalities and women's satisfaction with childbirth care in Brazil: a national hospital-based survey

The objective is to identify factors associated with women's satisfaction towards the care provided by the health professionals during hospital assisted delivery and identify how those factors influence their general levels of satisfaction. The cohort hospital based study was carried out in connection with the Birth in Brazil research. 15,688 women were included, interviewed at home, through the phone, from March 2011 to February 2012. All the variables that compose the professional/pregnant woman relationship (waiting time, respect, privacy, clarity of explanations, possibility of asking questions and participating in the decisions) and schooling remained independently associated with general satisfaction towards delivery care, in the adjusted model. The white women assisted in the southeastern and southern regions of the country, by the private sector and with a companion present gave a better evaluation of the care provided. Women value the way in which they are assisted by the health professionals, and there are inequalities in the way they are treated based on skin color, geographic region and financial situation.

Women and healthcare providers' perceptions of a midwife-led unit in a Swiss university hospital: a qualitative study

BACKGROUND

The development of medical-led care in obstetrics over the past decades has contributed to improving outcomes for both mother and child. Although efficiency has improved in complex situations, unnecessary interventions are still practiced in low-risk pregnancies, contrary to international recommendations. A shift to a less interventionist model of care has encouraged many countries to review their policies on maternal health care and develop models such as the "midwife-led unit" (MLU) where the midwife plays a predominant role with a minimum of routine intervention. Existing research has provided convincing evidence that MLUs lead to better maternal and neonatal outcomes when compared to traditional models. They not only improve the level of satisfaction amongst women, but are also associated with reduced healthcare costs. This study aimed to explore the perceptions of women and healthcare providers regarding the creation of an MLU in a Swiss university hospital.

METHODS

A descriptive research study using qualitative methods was conducted among pregnant women and new mothers in a Swiss maternity unit, including also midwives and medical staff. Data collection was carried out through one-to-one interviews, focus groups, and telephone interviews (n = 63). After transcription, thematic analysis was performed.

RESULTS

The triangulation of perceptions of women and healthcare providers indicated support for the implementation of an MLU to promote physiological delivery. Most women welcomed the idea of an MLU, in particular how it could help in offering continuity of care. Healthcare providers were optimistic about the implementation of an MLU and recognised the need for some women to have access to a less interventionist approach. From the women's perspective, barriers concerned the lack of awareness of midwives' full scope of practice, while barriers for midwives and obstetricians were related to the challenge to develop a good interprofessional collaboration.

CONCLUSION

Alternative models to provide maternity care for low-risk women have been developed and evaluated widely in several countries outside Switzerland. This study showed that women and healthcare providers were favourable towards the development of a new care model, while taking into account the specific expectations and barriers raised by participants.

Atenção ao pré-natal e parto em mulheres usuárias do sistema público de saúde residentes na Amazônia Legal e no Nordeste, Brasil 2010

Objetivos: descrever a adequação da atenção à saúde entre as mulheres que fizeram o pré-natal e/ou parto no Sistema Único de Saúde (SUS), nos municípios prioritários para a redução da mortalidade infantil na Amazônia Legal e no Nordeste. Métodos: análise de dados secundários de inquérito de base populacional com mães e crianças menores de um ano de idade que compareceram à Campanha de vacinação em 2010. A amostra estudada foi de 13.205 mulheres com acompanhamento de pré-natal e de 13.044 mulheres com acompanhamento de parto, em 252 municípios prioritários. A adequação do pré-natal e parto foi classificada em conformidade com indicadores de processo propostos pelo Programa Nacional de Humanização do Pré-natal e Nascimento. Resultados: entre as mulheres investigadas 75,4% realizaram seis ou mais consultas de pré-natal, mas somente 3,4% tiveram acesso a um pré-natal classificado como adequado. O acesso à ultrassonografia foi relatado por 96,1% das mulheres, ao exame de HIV por 91,8% e ao teste de sífilis por 68,7%. Apenas 44,2% das mulheres recebeu indicação da maternidade na qual deveria fazer o parto e a internação no local indicado ocorreu em 8,6% dos casos. A atenção ao parto foi considerada adequada para apenas 1% das entrevistadas. Os resultados variaram entre os estados e níveis socioeconômicos das mulheres. Conclusões: foram identificadas falhas na atenção ao pré-natal e parto, que é inadequada e socialmente iníqua nestas regiões, contribuindo para os precários indicadores de saúde materno infantil na Amazônia Legal e no Nordeste do Brasil.

O acompanhante no centro obstétrico de um hospital universitário do sul do Brasil

RESUMO Objetivos Verificar a prevalência de acompanhante, o tipo de vínculo com a mulher e as justificativas para sua ausência no Centro Obstétrico de um hospital universitário de Porto Alegre (RS). Métodos Estudo quantitativo, transversal, realizado com 385 mulheres no período de agosto a novembro de 2012. Procedeu-se à análise descritiva. Resultados Constataram-se 97,1% de acompanhantes no trabalho de parto; 90,6% no parto; 28,6% na recuperação pós-parto; e 87,1% na realização dos primeiros cuidados com o recém-nascido. O companheiro da mulher foi o acompanhante predominante em todos os momentos. O motivo mais citado para a sua ausência na recuperação pós-parto foi “não permitido” (57,8%). Conclusões A Instituição cumpre as determinações legais referentes à presença de acompanhante, no entanto, ainda há necessidade de sensibilização dos profissionais de saúde quanto à importância do acompanhante no pós-parto imediato, assim como de adequações do espaço físico do local, favorecendo a presença desse suporte à mulher.

Women's experiences of coping with pain during childbirth: a critical review of qualitative research

OBJECTIVE

to identify and analyse qualitative literature exploring women's experiences of coping with pain during childbirth.

DESIGN

critical review of qualitative research.

FINDINGS

ten studies were included, conducted in Australia, England, Finland, Iceland, Indonesia, Iran and Sweden. Eight of the studies employed a phenomenological perspective with the remaining two without a specific qualitative methodological perspective. Thematic analysis was used as the approach for synthesising the data in this review. Two main themes emerged as the most significant influences upon a woman's ability to cope with pain: (i) the importance of individualised, continuous support and (ii) an acceptance of pain during childbirth. This review found that women felt vulnerable during childbirth and valued the relationships they had with health professionals. Many of the women perceived childbirth pain as challenging, however, they described the inherent paradox for the need for pain to birth their child. This allowed them to embrace the pain subsequently enhancing their coping ability.

KEY CONCLUSIONS

women's experience of coping with pain during childbirth is complex and multifaceted. Many women felt the need for effective support throughout childbirth and described the potential implications where this support failed to be provided. Feeling safe through the concept of continuous support was a key element of care to enhance the coping ability and avoid feelings of loneliness and fear. A positive outlook and acceptance of pain was acknowledged by many of the women, demonstrating the beneficial implications for coping ability. These findings were consistent despite the socio-economic, cultural and contextual differences observed within the studies suggesting that experiences of coping with pain during childbirth are universal.

IMPLICATIONS FOR PRACTICE

the findings suggest there is a dissonance between what women want in order to enhance their ability to cope with pain and the reality of clinical practice. This review found women would like health professionals to maintain a continuous presence throughout childbirth and support a social model of care that promotes continuity of care and an increasing acceptance of pain as part of normal childbirth. It is suggested future research regarding the role of antenatal provision for instilling such a viewpoint in preparation of birth be undertaken to inform policy makers. The need for a shift in societal norms is also suggested to disseminate expectations and positive or negative views of what the role of pain during childbirth should be to empower women to cope with childbirth and embrace this transition to motherhood as part of a normal process.

Healthy birth practice #3: bring a loved one, friend, or doula for continuous support

All women should be allowed and encouraged to bring a loved one, friend, or doula to their birth without financial or cultural barriers. Continuous labor support offers benefits to mothers and their babies with no known harm. This article is an updated evidence-based review of the "Lamaze International Care Practices that Promote Normal Birth, Care Practice #3: Continuous Labor Support," published in The Journal of Perinatal Education, 16(3), 2007.

Evaluating the 'Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme': A mixed method study in England

BACKGROUND

caesarean section plays an important role in ensuring safety of mother and infant but rising rates are not accompanied by measurable improvements in maternal or neonatal mortality or morbidity. The 'Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme' was a facilitative initiative developed to promote opportunities for normal birth and reduce caesarean section rates in England.

OBJECTIVE

to evaluate the 'Focus on Normal Birth and Reducing Caesarean section Rates' programme, by assessment of: impact on caesarean section rates, use of service improvements tools and participants׳ perceptions of factors that sustain or hinder work within participating maternity units.

DESIGN

a mixed methods approach included analysis of mode of birth data, web-based questionnaires and in-depth semi-structured telephone interviews.

PARTICIPANTS

twenty Hospital Trusts in England (selected from 68 who applied) took part in the 'Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme' initiative. In each hospital Trust, the head of midwifery, an obstetrician, the relevant lead for organisational development, a supervisor of midwives, or a clinical midwife and a service user representative were invited to participate in the independent evaluation.

METHODS

collection and analysis of mode of birth data from 20 participating hospital Trusts, web-based questionnaires administered to key individuals in all 20 Trusts and in-depth semi-structured telephone interviews conducted with key individuals in a sample of six Trusts.

FINDINGS

there was a marginal decline of 0.5% (25.9% from 26.4%) in mean total caesarean section rate in the period 1 January 2009 to 31 January 2010 compared to the baseline period (1 July-31 December 2008). Reduced total caesarean section rates were achieved in eight trusts, all with higher rates at the beginning of the initiative. Features associated with lower caesarean section rates included a shared philosophy prioritising normal birth, clear communication across disciplines and strong leadership at a range of levels, including executive support and clinical leaders within each discipline.

CONCLUSIONS

it is important that the philosophy and organisational context of care are examined to identify potential barriers and facilitative factors.

Evidence from facility level inputs to improve quality of care for maternal and newborn health: interventions and findings

Most of the maternal and newborn deaths occur at birth or within 24 hours of birth. Therefore, essential lifesaving interventions need to be delivered at basic or comprehensive emergency obstetric care facilities. Facilities provide complex interventions including advice on referrals, post discharge care, long-term management of chronic conditions along with staff training, managerial and administrative support to other facilities. This paper reviews the effectiveness of facility level inputs for improving maternal and newborn health outcomes. We considered all available systematic reviews published before May 2013 on the pre-defined facility level interventions and included 32 systematic reviews. Findings suggest that additional social support during pregnancy and labour significantly decreased the risk of antenatal hospital admission, intrapartum analgesia, dissatisfaction, labour duration, cesarean delivery and instrumental vaginal birth. However, it did not have any impact on pregnancy outcomes. Continued midwifery care from early pregnancy to postpartum period was associated with reduced medical procedures during labour and shorter length of stay. Facility based stress training and management interventions to maintain well performing and motivated workforce, significantly reduced job stress and improved job satisfaction while the interventions tailored to address identified barriers to change improved the desired practice. We found limited and inconclusive evidence for the impacts of physical environment, exit interviews and organizational culture modifications. At the facility level, specialized midwifery teams and social support during pregnancy and labour have demonstrated conclusive benefits in improving maternal newborn health outcomes. However, the generalizability of these findings is limited to high income countries. Future programs in resource limited settings should utilize these findings to implement relevant interventions tailored to their needs.

The association between attendance of midwives and workload of midwives with the mode of birth: secondary analyses in the German healthcare system

Background

The continuous rise in caesarean rates across most European countries raises multiple concerns. One factor in this development might be the type of care women receive during childbirth. ‘Supportive care during labour’ by midwives could be an important factor for reducing fear, tension and pain and decreasing caesarean rates. The presence and availability of midwives to support a woman in line with her needs are central aspects for ‘supportive care during labour’.

To date, there is no existing research on the influence of effective ‘supportive care’ by German midwives on the mode of birth. This study examines the association between the attendance and workload of midwives with the mode of birth outcomes in a population of low-risk women in a German multicentre sample.

Methods

The data are based on a prospective controlled multicentre trial (n = 1,238) in which the intervention ‘midwife-led care’ was introduced. Four German hospitals participated between 2007 and 2009.

Secondary analyses included a convenience sample of 999 low-risk women from the primary analyses who met the selection criterion ‘low-risk status’. Participation was voluntary. The association between the mode of birth and the key variables ‘attendance of midwives’ and ‘workload of midwives’ was assessed using backward logistic regression models.

Results

The overall rate of spontaneous delivery was 80.7% (n = 763). The ‘attendance of midwives’ and the ‘workload of midwives’ did not exhibit a significant association with the mode of birth. However, women who were not satisfied with the presence of midwives (OR: 2.45, 95% CI 1.54-3.95) or who did not receive supportive procedures by midwives (OR: 3.01, 95% CI 1.50-6.05) were significantly more likely to experience operative delivery or a caesarean. Further explanatory variables include the type of hospital, participation in childbirth preparation class, length of stay from admission to birth, oxytocin usage and parity.

Conclusion

Satisfaction with the presence of and supportive procedures by midwives are associated with the mode of birth. The presence and behaviour of midwives should suit the woman’s expectations and fulfil her needs. For reasons of causality, we would recommend experimental or quasi-experimental research that would exceed the explorative character of this study.

Pesquisa Nascer no Brasil: perfil da mortalidade neonatal e avaliação da assistência à gestante e ao recém-nascido

Estudo de coorte sobre a mortalidade neonatal na pesquisa Nascer no Brasil, com entrevista e avaliação de prontuários de 23.940 puérperas entre fevereiro de 2011 e outubro de 2012. Utilizou-se modelagem hierarquizada para análise dos potenciais fatores de risco para o óbito neonatal. A taxa de mortalidade foi 11,1 por mil; maior nas regiões Norte e Nordeste e nas classes sociais mais baixas. O baixo peso ao nascer, o risco gestacional e condições do recém-nascido foram os principais fatores associados ao óbito neonatal. A inadequação do pré-natal e da atenção ao parto indicaram qualidade não satisfatória da assistência. A peregrinação de gestantes para o parto e o nascimento de crianças com peso < 1.500g em hospital sem UTI neonatal demonstraram lacunas na organização da rede de saúde. Óbitos de recém-nascidos a termo por asfixia intraparto e por prematuridade tardia expressam a evitabilidade dos óbitos. A qualificação da atenção, em especial da assistência hospitalar ao parto se configura como foco prioritário para maiores avanços nas políticas públicas de redução das taxas e das desigualdades na mortalidade infantil no Brasil.

Effect of the presence of support person and routine intervention for women during childbirth in Isfahan, Iran: A randomized controlled trial

Background:

The aim of this study was to examine the effects of the presence of continuous support person and routine interventions during labor and delivery in Isfahan, Iran.

Materials and Methods:

One hundred pregnant women in spontaneous labor were assessed in four groups: Group 1; received routine intervention with a support person, Group 2; received routine intervention without support person, Group 3; received support person without routine intervention, Group 4; did not receive routine intervention or a support person. Sociodemographic, antenatal characteristics, length of stage of labor, instrumental delivery, the cervical laceration, perineal tear, labor pain, satisfaction and Apgar score collected and analyzed.

Results:

Based on the results there was no significant difference in regard to maternal age, BMI, maternal education and working statutes among the studied groups (P-value >0.05). Also, 1 and 5-min Apgar <7, cervical lacerations and instrumental delivery among studied groups were similar (P-value >0.05). Length of first and second stage of labor, perineal tear, satisfaction score and pain before and after labor were significant among studied groups (P-value <0.05).

Conclusions:

Presence of a support person and routine intervention during labor did not effect on incidence of cervical lacerations, instrumental delivery and Apgar <7. Labor pain and women's dissatisfaction, and number women with third and fourth degree of perineal tear among women who received routine intervention were increased compare to others. Interventions makes decreased the length of first and second stage of labor. In totally, the presence of a support person during labor in Iranian women decrease length of labor and improved labor outcomes.

Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost?

Progress in newborn survival has been slow, and even more so for reductions in stillbirths. To meet Every Newborn targets of ten or fewer neonatal deaths and ten or fewer stillbirths per 1000 births in every country by 2035 will necessitate accelerated scale-up of the most effective care targeting major causes of newborn deaths. We have systematically reviewed interventions across the continuum of care and various delivery platforms, and then modelled the effect and cost of scale-up in the 75 high-burden Countdown countries. Closure of the quality gap through the provision of effective care for all women and newborn babies delivering in facilities could prevent an estimated 113,000 maternal deaths, 531,000 stillbirths, and 1·325 million neonatal deaths annually by 2020 at an estimated running cost of US$4·5 billion per year (US$0·9 per person). Increased coverage and quality of preconception, antenatal, intrapartum, and postnatal interventions by 2025 could avert 71% of neonatal deaths (1·9 million [range 1·6-2·1 million]), 33% of stillbirths (0·82 million [0·60-0·93 million]), and 54% of maternal deaths (0·16 million [0·14-0·17 million]) per year. These reductions can be achieved at an annual incremental running cost of US$5·65 billion (US$1·15 per person), which amounts to US$1928 for each life saved, including stillbirths, neonatal, and maternal deaths. Most (82%) of this effect is attributable to facility-based care which, although more expensive than community-based strategies, improves the likelihood of survival. Most of the running costs are also for facility-based care (US$3·66 billion or 64%), even without the cost of new hospitals and country-specific capital inputs being factored in. The maximum effect on neonatal deaths is through interventions delivered during labour and birth, including for obstetric complications (41%), followed by care of small and ill newborn babies (30%). To meet the unmet need for family planning with modern contraceptives would be synergistic, and would contribute to around a halving of births and therefore deaths. Our analysis also indicates that available interventions can reduce the three most common cause of neonatal mortality--preterm, intrapartum, and infection-related deaths--by 58%, 79%, and 84%, respectively.

Aromatherapy with citrus aurantium oil and anxiety during the first stage of labor

BACKGROUND

Anxiety is the most common psychological response of women to labor. Aromatherapy, i.e. the use of fragrant essential oils to stimulate the olfactory system, can create a state of calmness and help to alleviate anxiety.

OBJECTIVES

The present study tried to determine the efficacy of aromatherapy with Citrus aurantium oil in reducing anxiety during the first stage of labor.

PATIENTS AND METHODS

This randomized clinical trial was conducted on two groups of pregnant women, referred to Vali-Asr Hospital (Tuyserkan, Iran) between June and September 2013. The sample size was comprised of 63 subjects in each group. Gauzes impregnated with 4 mL of C. aurantium distillate and normal saline were attached to the collar of subjects in the aromatherapy and control groups, respectively. The gauzes were changed every 30 minutes. The levels of anxiety in both groups were measured at baseline and after the intervention at dilations of 3-4 and 6-8 cm. The participants were followed up until delivery and the first- and fifth-minute Apgar scores were recorded. Data were collected using a demographic and obstetric characteristics questionnaire, an examination and observation checklist, and Spielberger state-trait anxiety questionnaire. Data analysis was performed with independent-t, Mann-Whitney, and chi-square tests in SPSS-22. P values less than 0.05 were considered significant.

RESULTS

Before the intervention, both groups had same levels of anxiety. However, the levels of anxiety at dilations of 3-4 and 6-8 cm were significantly lower in the aromatherapy group compared with the control group.

CONCLUSIONS

The results of this study confirmed aromatherapy with C. aurantium blossom oil as a simple, inexpensive, noninvasive, and effective intervention to reduce anxiety during labor.

Uterine contractions' pattern in active phase of labor as a predictor of failure to progress

BACKGROUND

Failure to progress remains a key indication for cesarean section which caused by different factors including uterine contractions. If it is diagnosed in the primary phase of labor, a better prognosis can thus be made. The purpose of this study was to find a possible correlation between pattern of uterine contraction and progression of labor.

METHOD

During this study, 120 women referred for delivery to an educational hospital's maternity ward in the North of Iran in 2010 were included. Uterine contractions of mothers were recorded in dilatation of 4 to7 cm for an hour. In this way, F/R ratio which means the time that a contraction needs to return from its peak to baseline (Fall) divided to the time for a contraction to rise to its peak (Rise) was calculated. All of the participants were followed until delivery, vaginal delivery or caesarean section.

RESULTS

Mean and standard deviation of fall to raise ratio was 1.54±0.26 in mothers with vaginal delivery versus 1.74±0.21 for others underwent caesarean section (OR = 0.44, 95% CI: 0.005- 0.42, P < 0.001). Sensitivity, specificity, and predictive values (positive and negative) of mentioned ratio were 68.32%, 70.01%, 69.55%, and 68.91%, respectively.

CONCLUSION

By considering acceptable predictive value of uterine contractions' pattern in the active phase of labor, it could help to timely diagnosis of failure to progress and consequently suitable intervention which probably maintain better health of both mother and fetus.

Maternal Obesity and the First Birth: A Case for Targeted Contemporary Maternity Care

BACKGROUND: Obesity in childbearing women is associated with poorer pregnancy and birth outcomes, particularly caesarean section, compared with normal-weight women. The high caesarean section rate may reflect care and outcomes which occur at the time surrounding the first birth.

AIM: To describe the birth outcomes of extremely obese pregnant women (body mass index [BMI] of 40 or more) experiencing their first birth.

METHODS: Clinical audit was used to systematically review the care and birth outcomes of all extremely obese pregnant women experiencing their birth at one study site during a 2-year period in 2009 and 2010. Fifty participants birthed during the study period. Data were collected from booking to discharge from the maternity service and included variables such as model of care, number of appointments, and obstetric and neonatal outcomes. Descriptive statistics were used to describe and synthesize the data. Inferential statistics were used to draw inferences about the population.

RESULTS: Obese women rarely had contact with a midwife, except at booking, receiving a standard model of care provided by numerous caregivers, most often inexperienced medical staff. More than half of the obese women experienced a caesarean section (56%), 2.3 times that of normal-weight primiparous women who birthed at the study site during the same period (24.2%). This was despite 64% experiencing normal pregnancy free from any complication. For women who planned to labor, birth intervention including induction of labor, augmentation for slow labor, epidural, and continuous cardiotocography was high. Caesarean occurred most often for “failure to progress” and “failed induction.”

CONCLUSION: Clinical audit was useful in determining information, which suggests current maternity care provision is not meeting the needs of extremely obese women experiencing their first birth.

IMPLICATIONS FOR PRACTICE: The development of effective, targeted antenatal care designed to meet the needs of extremely obese women is recommended as are strategies to keep birth normal.

Dutch women in midwife-led care at the onset of labour: which pain relief do they prefer and what do they use?

Background

Pain experienced during labour is more extreme than many other types of physical pain. Many pregnant women are concerned about labour pain and about how they can deal with this pain effectively.

The aim of this study was to examine the associations among low risk pregnant women’s characteristics and their preferred use and actual use of pain medication during labour.

Methods

Our study is part of the DELIVER study: a dynamic prospective multi-centre cohort study. The data for this study were collected between September 2009 and March 2011, from women at 20 midwifery practices throughout the Netherlands. Inclusion criteria for women were: singleton pregnancies, in midwife–led care at the onset of labour and speaking Dutch, English, Turkish or Arabic. Our study sample consisted of 1511 women in primary care who completed both questionnaire two (from 34 weeks of pregnancy up to birth) and questionnaire three (around six week post partum). These questionnaires were presented either online or on paper.

Results

Fifteen hundred and eleven women participated. Prenatally, 15.9% of women preferred some method of medicinal pain relief. During labour 15.2% of the total sample used medicinal pain relief and 25.3% of the women who indicated a preference to use medicinal pain relief during pregnancy, used pain medication. Non-Dutch ethnic background and planned hospital birth were associated with indicating a preference for medicinal pain relief during pregnancy. Primiparous and planned hospital birth were associated with actual use of the preferred method of medicinal pain relief during labour. Furthermore, we found that 85.5% of women who indicated a preference not to use pain medication prenatally, did not use any medication.

Conclusions

Only a small minority of women had a preference for intrapartum pain medication prenatally. Most women did not receive medicinal pain relief during labour, even if they had indicated a preference for it.

Care providers should discuss the unpredictability of the labour process and the fact that actual use of pain medication often does not match with women’s preference prenatally.

Use of nonmedical methods of labor induction and pain management among U.S. women

BACKGROUND

There exists limited documentation of nonmedical methods of labor induction and pain management during childbirth in the United States. We estimated the prevalence of nonmedical interventions for induction and pain management and examined the association between medical and nonmedical care during labor.

METHODS

We used a nationally representative survey of U.S. women who gave birth in 2005 (N = 1,382) to examine use of nonmedical methods of labor induction and pain management. Using logistic regression, we calculated odds of nonmedical and medical interventions to induce labor or mitigate pain, and the odds of medical induction and obstetric analgesia by whether nonmedical methods were reported.

RESULTS

Nearly 30 percent of women used nonmedical methods to start labor, and over 70 percent of women used nonmedical pain management. Doula support was the strongest predictor of nonmedical methods of labor induction (Adjusted Odds Ratio [AOR] = 3.0) and labor pain management (AOR = 5.7). Use of nonmedical pain management was significantly associated with decreased odds of medical pain management (OR = 0.65); this relationship was attenuated with covariate adjustment.

CONCLUSIONS

Nonmedical methods to induce labor and manage pain during childbirth are commonly used by U.S. women. Future research should examine effectiveness of these strategies and their influence on medical services use.

Association between anxiety and pain in the latent phase of labour upon admission to the maternity hospital: a prospective, descriptive study

This study investigated the association between anxiety experienced by the mother, a request for analgesia, and the level of pain at maternity hospital admission in early labour. Anxiety levels were measured by the State-Trait Anxiety Inventory and pain was assessed using a Visual Analogue Scale. Anxiety and Visual Analogue Scale scores were compared using a linear regression model and indicated a statistically significant association between the anxiety state and degree of pain (p < 0.016; Y = 0.895 x score + 32.656). There was no significant association between anxiety and a request for epidural analgesia. During labour, an evaluation of anxiety should be associated with an assessment of the perceived degree of pain.

Evaluation of the Bonapace Method: a specific educational intervention to reduce pain during childbirth

OBJECTIVE

As pain during childbirth is very intense, several educational programs exist to help women prepare for the event. This study evaluates the efficacy of a specific pain management program, the Bonapace Method (BM), to reduce the perception of pain during childbirth. The BM involves the father, or a significant partner, in the use of several pain control techniques based on three neurophysiological pain modulation models: (1) controlling the central nervous system through breathing, relaxation, and cognitive structuring; (2) using non-painful stimuli as described in the Gate Control Theory; and (3) recruiting descending inhibition by hyperstimulation of acupressure trigger points.

METHODS

A multicenter case control study in Quebec on pain perception during labor and delivery compared traditional childbirth training programs (TCTPs) and the BM. Visual analog scales were used to measure pain perception during labor. In all, 25 women (TCTP: n = 12; BM: n = 13) successfully reported their perceptions of pain intensity and unpleasantness every 15 minutes.

RESULTS

A POSITIVE CORRELATION BETWEEN THE PROGRESSION OF LABOR AND PAIN WAS FOUND (PAIN INTENSITY: P < 0.01; pain unpleasantness: P < 0.01). When compared to TCTP, the BM showed an overall significant lower pain perception for both intensity (45%; P < 0.01) and unpleasantness (46%; P < 0.01).

CONCLUSION

These significant differences in pain perception between TCTP and the BM suggest that the emphasis on pain modulation models and techniques during labor combined with the active participation of a partner in BM are important variables to be added to the traditional childbirth training programs for childbirth pain management.

O familiar acompanhante como estimulo comportamental de pacientes internados em terapia intensiva

O objetivos deste estudo foram levantar as expressões verbais e não verbais presentes no comportamento do paciente antes, durante a inserção e permanência do familiar acompanhante no centro de terapia intensiva, e analisar comparativamente as alterações comportamentais do paciente durante esses momentos da internação. MÉTODO: O cenário foi o centro de terapia intensiva de um hospital no Rio de Janeiro, conveniado com o Sistema Único de Saúde (SUS). A abordagem qualitativa resultou da observação livre sobre o comportamento de cinco pacientes e registros em diário de campo durante três dias consecutivos. Priorizou-se observação do paciente no primeiro dia de internação e após a inserção ininterrupta do familiar acompanhante por três dias consecutivos. RESULTADOS: As mudanças nas reações verbais e não verbais do paciente após os estímulos gerados pela presença do familiar variaram de ausência de fala e movimentos, passividade no agir, a reações de aceitação dos procedimentos, comunicação cinésica ampliada e maior participação no cuidado.

Continuous support for women during childbirth

BACKGROUND

Historically, women have been attended and supported by other women during labour. However, in hospitals worldwide, continuous support during labour has become the exception rather than the routine.

OBJECTIVES

Primary: to assess the effects of continuous, one-to-one intrapartum support compared with usual care. Secondary: to determine whether the effects of continuous support are influenced by: (1) routine practices and policies; (2) the provider's relationship to the hospital and to the woman; and (3) timing of onset.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2013).

SELECTION CRITERIA

All published and unpublished randomised controlled trials comparing continuous support during labour with usual care.

DATA COLLECTION AND ANALYSIS

We used standard methods of The Cochrane Collaboration Pregnancy and Childbirth Group. Two review authors independently evaluated methodological quality and extracted the data. We sought additional information from the trial authors. We used random-effects analyses for comparisons in which high heterogeneity was present, and we reported results using the average risk ratio (RR) for categorical data and mean difference (MD) for continuous data.

MAIN RESULTS

Twenty-two trials involving 15,288 women met inclusion criteria and provided usable outcome data. Results are of random-effects analyses, unless otherwise noted. Women allocated to continuous support were more likely to have a spontaneous vaginal birth (RR 1.08, 95% confidence interval (CI) 1.04 to 1.12) and less likely to have intrapartum analgesia (RR 0.90, 95% CI 0.84 to 0.96) or to report dissatisfaction (RR 0.69, 95% CI 0.59 to 0.79). In addition, their labours were shorter (MD -0.58 hours, 95% CI -0.85 to -0.31), they were less likely to have a caesarean (RR 0.78, 95% CI 0.67 to 0.91) or instrumental vaginal birth (fixed-effect, RR 0.90, 95% CI 0.85 to 0.96), regional analgesia (RR 0.93, 95% CI 0.88 to 0.99), or a baby with a low five-minute Apgar score (fixed-effect, RR 0.69, 95% CI 0.50 to 0.95). There was no apparent impact on other intrapartum interventions, maternal or neonatal complications, or breastfeeding. Subgroup analyses suggested that continuous support was most effective when the provider was neither part of the hospital staff nor the woman's social network, and in settings in which epidural analgesia was not routinely available. No conclusions could be drawn about the timing of onset of continuous support.

AUTHORS' CONCLUSIONS

Continuous support during labour has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labour and birth.

Doula care supports near-universal breastfeeding initiation among diverse, low-income women

INTRODUCTION

Breastfeeding initiation rates in the United States have risen in recent years. However, there are notable disparities by socioeconomic status and race/ethnicity. Previous research has suggested that care from a doula (a trained professional who provides nonmedical support during the perinatal period) may increase breastfeeding initiation. The goal of this analysis was to study whether doula support may be associated with breastfeeding initiation among low-income, diverse women.

METHODS

We compared breastfeeding initiation rates (means and 95% confidence intervals) for 1069 women who received doula care from Everyday Miracles, a Minnesota-based organization that employs a diverse group of certified doulas, to a state-based sample of women with Medicaid coverage who gave birth in 2009 or 2010 and participated in the Minnesota Pregnancy Risk Assessment Monitoring System survey (weighted n = 51,721).

RESULTS

Women who had doula-supported births had near-universal breastfeeding initiation (97.9%), compared with 80.8% of the general Medicaid population. Among African American women, 92.7% of those with doula support initiated breastfeeding, compared with 70.3% of the general Medicaid population.

DISCUSSION

These results suggest that access to culturally appropriate doula care may facilitate higher rates of breastfeeding initiation. When supported in their nonmedical needs by birth doulas, the diverse, low-income patients of midwives and other maternity care providers may have a greater likelihood of initiating breastfeeding and experiencing the maternal and infant health benefits associated with breastfeeding.

Breast milk and labour support: lactation consultants' and doulas' strategies for navigating the medical context of maternity care

This article provides a comparison of two occupational groups working in maternity care: International Board Certified Lactation Consultants, who assist women with breastfeeding, and DONA International certified birth doulas, who provide physical, emotional and informational support to birthing women. Using interviews with 18 lactation consultants and 16 doulas working in the USA, I compare these two groups' strategies for gaining entrance to the maternity care team and their abilities to create change in maternity care practices. Due to the organisation of occupational boundaries in maternity care and differences between the influence of the medicalisation of breastfeeding versus that of childbirth on those boundaries, lactation consultants are able to utilise a front-door entrance to the medical maternity system, entering as lactation specialists and advocates, while doulas use a back-door entrance, emphasising their care work and downplaying their advocacy. These different strategies result in different methods being available to each for effecting change. Lactation consultants create formal change, such as changing hospital policies and practices to be more pro-breastfeeding. Doulas create change informally, 'one birth at a time', by creating space for natural birth to occur in the hospital, as well as exposing medical providers to non-medical ways of giving birth.

What do midwives need to know about approaches of women towards labour pain management? A qualitative interview study into expectations of management of labour pain for pregnant women receiving midwife-led care in the Netherlands

OBJECTIVE

to investigate factors important to women receiving midwife-led care with regard to their expectations for management of labour pain.

DESIGN

semi-structured ante partum interviews and analyses using constant comparison method.

PARTICIPANTS

fifteen pregnant women between 36 and 40 weeks gestation receiving midwife-led care.

SETTING

five midwifery practices across the Netherlands between June 2009 and July 2010.

MAIN OUTCOME

women's expectations regarding management of labour pain.

RESULTS

we found three major themes to be important in women's expectations for management of labour pain: preparation, support and control and decision-making. In regards to all these themes, three distinct approaches towards women's planning for pain management in labour were identified: the 'pragmatic natural', the 'deliberately uninformed' and the 'planned pain relief' approach.

CONCLUSION

midwives need to recognise that women take different approaches to pain management in labour in order to adapt care to the individual woman.

Misrecognition of need: women's experiences of and explanations for undergoing cesarean delivery

International rates of operative delivery are consistently higher than the World Health Organization determined is appropriate. This suggests that factors other than clinical indications contribute to cesarean section. Data presented here are from interviews with 115 mothers on the postnatal ward of a hospital in Northeast England during February 2006 to March 2009 after the women underwent either unscheduled or scheduled cesarean childbirth. Using thematic content analysis, we found women's accounts of their experiences largely portrayed cesarean section as everything that they had wanted to avoid, but necessary given their situations. Contrary to popular suggestion, the data did not indicate impersonalized medical practice, or that cesareans were being performed 'on request.' The categorization of cesareans into 'emergency' and 'elective' did not reflect maternal experiences. Rather, many unscheduled cesareans were conducted without indications of fetal distress and most scheduled cesareans were not booked because of 'choice.' The authoritative knowledge that influenced maternal perceptions of the need to undergo operative delivery included moving forward from 'prolonged' labor and scheduling cesarean as a prophylactic to avoid anticipated psychological or physical harm. In spontaneously defending themselves against stigma from the 'too posh to push' label that is currently common in the media, women portrayed debate on the appropriateness of cesarean childbirth as a social critique instead of a health issue. The findings suggest the 'need' for some cesareans is due to misrecognition of indications by all involved. The factors underlying many cesareans may actually be modifiable, but informed choice and healthful outcomes are impeded by lack of awareness regarding the benefits of labor on the fetal transition to extrauterine life, the maternal desire for predictability in their parturition and recovery experiences, and possibly lack of sufficient experience for providers in a variety of vaginal delivery scenarios (non-progressive labor, breech presentation, and/or after previous cesarean).

Incidence of and risk factors for perineal trauma: a prospective observational study

BACKGROUND

Our aim was to describe the range of perineal trauma in women with a singleton vaginal birth and estimate the effect of maternal and obstetric characteristics on the incidence of perineal tears.

METHODS

We conducted a prospective observational study on all women with a planned singleton vaginal delivery between May and September 2006 in one obstetric unit, three freestanding midwifery-led units and home settings in South East England. Data on maternal and obstetric characteristics were collected prospectively and analysed using univariable and multivariable logistic regression. The outcome measures were incidence of perineal trauma, type of perineal trauma and whether it was sutured or not.

RESULTS

The proportion of women with an intact perineum at delivery was 9.6% (125/1,302) in nulliparae, and 31.2% (453/1,452) in multiparae, with a higher incidence in the community (freestanding midwifery-led units and home settings). Multivariable analysis showed multiparity (OR 0.52; 95% CI: 0.30-0.90) was associated with reduced odds of obstetric anal sphincter injuries (OASIS), whilst forceps (OR 4.43; 95% CI: 2.02-9.71), longer duration of second stage of labour (OR 1.49; 95% CI: 1.13-1.98), and heavier birthweight (OR 1.001; 95% CI: 1.001-1.001), were associated with increased odds. Adjusted ORs for spontaneous perineal truama were: multiparity (OR 0.42; 95% CI: 0.32-0.56); hospital delivery (OR 1.48; 95% CI: 1.01-2.17); forceps delivery (OR 2.61; 95% CI: 1.22-5.56); longer duration of second stage labour (OR 1.45; 95% CI: 1.28-1.63); and heavier birthweight (OR 1.001; 95% CI: 1.000-1.001).

CONCLUSIONS

This large prospective study found no evidence for an association between many factors related to midwifery practice such as use of a birthing pool, digital perineal stretching in the second stage, hands off delivery technique, or maternal birth position with incidence of OASIS or spontaneous perineal trauma. We also found a low overall incidence of OASIS, and fewer second degree tears were sutured in the community than in the hospital settings. This study confirms previous findings of overall high incidence of perineal trauma following vaginal delivery, and a strong association between forceps delivery and perineal trauma.

Characteristics in the first vaginal birth and their association with mode of delivery in the subsequent birth

BACKGROUND

The extent to which complications or adverse outcomes in a first vaginal birth may contribute to mode of delivery in the next birth remains unclear. This study examines the impact of the first birth on subsequent mode of delivery.

METHODS

The study population included women with a first vaginal birth and a consecutive second birth. Data were obtained from linked birth and hospital records for the state of New South Wales, Australia 2000-09. The primary outcome was the mode of delivery for the second birth. Planned caesarean was modelled using logistic regression; intrapartum caesarean and instrumental delivery were modelled using multinomial logistic regression.

RESULTS

Of the 114 287 second births, 4.2% were planned caesarean, 3.0% were intrapartum caesarean and 4.8% were instrumental deliveries. Adjusted risk factors from the first birth for a planned second birth caesarean were third to fourth degree tear [odds ratio (OR) = 5.0 [95% confidence interval (CI) 4.6, 5.4]], severe neonatal morbidity (OR = 3.2 [95% CI 2.9, 3.6]), perinatal death (OR = 3.2 [95% CI 2.3, 4.4]), severe maternal morbidity (OR = 2.8 [95% CI 2.3, 3.3]), instrumental delivery, large infant, labour induction, epidural use, use of oxytocin for augmentation and episiotomy. Important risk factors (OR > 2) for intrapartum caesarean in the second birth were perinatal death or severe neonatal morbidity in the first birth. Risk factors for instrumental delivery in the second birth were perinatal death, preterm delivery and instrumental delivery.

CONCLUSIONS

Obstetrical interventions and adverse pregnancy outcomes in the first birth were associated with increased risk of operative delivery in the second birth.