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Weckend M, McCullough K, Duffield C, Bayes S, Davison C. Failure to progress or just normal? A constructivist grounded theory of physiological plateaus during childbirth. Women Birth 2024; 37:229-239. [PMID: 37867094 DOI: 10.1016/j.wombi.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 10/08/2023] [Accepted: 10/09/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND AND PROBLEM During childbirth, one of the most common diagnoses of pathology is 'failure to progress', frequently resulting in labour augmentation and intervention cascades. However, failure to progress is poorly defined and evidence suggests that some instances of slowing, stalling and pausing labour patterns may represent physiological plateaus. AIM To explore how midwives conceptualise physiological plateaus and the significance such plateaus may have for women's labour trajectory and birth outcome. METHODS Twenty midwives across Australia participated in semi-structured interviews between September 2020 and February 2022. Constructivist grounded theory methodology was applied to analyse data, including multi-phasic coding and application of constant comparative methods, resulting in a novel theory of physiological plateaus that is firmly supported by participant data. FINDINGS This study found that the conceptualisation of plateauing labour depends largely on health professionals' philosophical assumptions around childbirth. While the Medical Dominant Paradigm frames plateaus as invariably pathological, the Holistic Midwifery Paradigm acknowledges plateaus as a common and valuable element of labour that serves a self-regulatory purpose and results in good birth outcomes for mother and baby. DISCUSSION Contemporary medicalised approaches in maternity care, which are based on an expectation of continuous labour progress, appear to carry a risk for a misinterpretation of physiological plateaus as pathological. CONCLUSION This study challenges the widespread bio-medical conceptualisation of plateauing labour as failure to progress, encourages a renegotiation of what can be considered healthy and normal during childbirth, and provides a stimulus to acknowledge the significance of childbirth philosophy for maternity care practice.
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Affiliation(s)
- Marina Weckend
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, WA, Australia.
| | - Kylie McCullough
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, WA, Australia
| | - Christine Duffield
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, WA, Australia; Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Sara Bayes
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, WA, Australia; Faculty of Health Sciences, School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Fitzroy, VIC, Australia
| | - Clare Davison
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, WA, Australia; Ngangk Yira Institute for Change, Murdoch University, Murdoch, WA, Australia
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Is gestational age at term a risk factor for ongoing pregnancies in nulliparous women: A prospective cohort study. Am J Obstet Gynecol MFM 2023; 5:100808. [PMID: 36371036 DOI: 10.1016/j.ajogmf.2022.100808] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 11/06/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND The results of American observational studies and 1 large, randomized trial show that elective induction of labor among nulliparous women can reduce cesarean delivery rates and suggest that gestational age at delivery may be a risk factor for cesarean delivery in pregnancies managed expectantly. However, data on the risk of cesarean delivery at term in ongoing pregnancies are sparse, especially in high-income countries, and further information is needed to explore the external validity of these previous studies. OBJECTIVE This study aimed to evaluate the risk of cesarean delivery for each gestational week of ongoing pregnancy in nulliparous women with a singleton fetus in the cephalic presentation at term in a French population. STUDY DESIGN This retrospective study was conducted in a perinatal network of 10 maternity units from January 1, 2016, to December 31, 2017, and included all nulliparous women with a singleton fetus in the cephalic presentation who gave birth at term (≥37 0/7 weeks of gestation). From the start of term (37 completed weeks) and at the start of each subsequent week of completed gestation (each week + 0 days), ongoing pregnancy was defined as that of a woman who was still pregnant and who gave birth at any time after that date. For each week of gestation for these ongoing pregnancies, the cesarean delivery rate was defined as the number of cesarean deliveries performed in each ongoing pregnancy group divided by the number of women in this group. Separate models for each week of gestation, adjusted by maternal characteristics and hospital status, were used to compare the cesarean delivery risk between ongoing pregnancies and those delivered the preceding week. The same methods were applied to subgroups defined according to the mode of labor onset. Odds ratios were calculated after adjusting for maternal age and educational level, presence of severe preeclampsia, and maternity unit status. RESULTS The study included 11,308 nulliparous women, 2544 (22.5%) of whom had a cesarean delivery. These rates remained stable for ongoing pregnancies at 37 0/7, 38 0/7, and 39 0/7 weeks of gestation; the rates were 22.5% (95% confidence interval, 21.7-23.2), 22.6% (95% confidence interval, 21.8-23.3); and 22.7% (95% confidence interval, 21.9-23.6), respectively. The risk of cesarean delivery started to increase in ongoing pregnancies at 40 0/7 weeks of gestation (24.3%; 95% confidence interval, 23.1-25.4) and especially at 41 0/7 weeks of gestation (30.7%; 95% confidence interval, 28.9-32.5). Similar trends were also shown for all modes of labor onset and in every maternity unit. In univariate and multivariate analyses, ongoing pregnancy at or beyond 40 0/7 weeks of gestation was associated with a higher risk of cesarean delivery than pregnancy delivered the previous week: 24.3% of ongoing pregnancies at 40 0/7 weeks of gestation vs 19.9% of deliveries between 39 0/7 weeks of gestation and 39 6/7 weeks of gestation. The odds ratios were 1.28 (95% confidence interval, 1.15-1.44) or 30.4% of ongoing pregnancies at 41 0/7 weeks of gestation vs 1.73 (95% confidence interval, 1.51-1.96) or 19.6% of deliveries between 40 0/7 weeks of gestation and 40 6/7 weeks of gestation. CONCLUSION Cesarean delivery rates increased starting at 40 0/7 weeks of gestation in ongoing pregnancies regardless of the mode of labor onset.
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Lorentzen IP, Andersen CS, Jensen HS, Fogsgaard A, Foureur M, Lauszus FF, Nohr EA. Does giving birth in a "birth environment room" versus a standard birth room lower augmentation of labor? - Results from a randomized controlled trial. Eur J Obstet Gynecol Reprod Biol X 2021; 10:100125. [PMID: 33817626 PMCID: PMC8010388 DOI: 10.1016/j.eurox.2021.100125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 02/05/2021] [Accepted: 03/08/2021] [Indexed: 11/03/2022] Open
Abstract
Objective In the last decade, there has been an increased interest in exploring the impact of the physical birth environment on midwifery practice and women's birth experiences. This study is based on the hypothesis that the environment for birth needs greater attention to improve some of the existing challenges in modern obstetric practice, for example the increasing use of augmentation and number of interventions during delivery. Study design A randomized controlled trial was carried out to study the effect of giving birth in a specially designed "birth environment room" on the use of augmentation during labor. The study took place at the Department of Obstetrics and Gynecology, Herning Hospital, Denmark and included 680 nulliparous women in spontaneous labor at term with a fetus in cephalic presentation. Women were randomly allocated to either the "birth environment room" or a standard birth room. The primary outcome was augmentation of labor by use of oxytocin. Secondary outcomes were duration of labor, use of pharmacological pain relief, and mode of birth. Differences were estimated as relative risks (RR) and presented with 95% confidence intervals. Results No difference was found on the primary outcome, augmentation of labor (29.1% in the "birth environment room" versus 30.6% in the standard room, RR 0.97; 0.89-1.08). More women in the "birth environment room" used the bathtub (60.6% versus 52.4%, RR 1.18; 1.02-1.37), whereas a tendency to lower use of epidural analgesia (22.6% versus 28.2%) did not reach statistical significance (RR 0.87; 0.74-1.02). The chance of an uncomplicated birth was almost similar in the two groups (70.6% in the "birth environment room" versus 72.6% in the standard room, RR 0.97; 0.88-1.07) as were duration of labor (mean 7.9 hours in both groups). Conclusions Birthing in a specially designed physical birth environment did not lower use of oxytocin for augmentation of labor. Neither did it have any effect on duration of labor, use of pharmacological pain relief, and chance of birthing without complications. We recommend that future trials are conducted in birth units with greater improvement potentials.
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Affiliation(s)
| | - Charlotte S Andersen
- Department of Gynecology and Obstetrics, Gl. Landevej 61, 7400, Herning, Denmark
| | | | - Ann Fogsgaard
- Department of Gynecology and Obstetrics, Gl. Landevej 61, 7400, Herning, Denmark
| | - Maralyn Foureur
- Nursing and Midwifery Research Centre, Hunter New England Health and University of Newcastle, NSW, 2300, Australia
| | - Finn Friis Lauszus
- Department of Gynecology and Obstetrics, Gl. Landevej 61, 7400, Herning, Denmark
| | - Ellen Aagaard Nohr
- Research Unit for Obstetrics and Gynecology, Institute of Clinical Research, University of Southern Denmark, Campusvej 55, 5230, Odense C, Denmark.,Centre of Women's, Family and Child Health, University of South-Eastern Norway, Kongsberg, Norway
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Girault A, Blondel B, Goffinet F, Le Ray C. Frequency and determinants of misuse of augmentation of labor in France: A population-based study. PLoS One 2021; 16:e0246729. [PMID: 33561131 PMCID: PMC7872232 DOI: 10.1371/journal.pone.0246729] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 01/25/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction While use of augmentation of labor (AL) is appropriate for labor dystocia, it is frequently used inadequately and unnecessarily. The objective was to assess at a national level, the frequency and determinants of misuse of augmentation of labor (AL). Material and methods Women of the French perinatal survey of 2016 with a singleton cephalic fetus, delivering at term after a spontaneous labor were included. “Misuse of AL” was defined by artificial rupture of the membranes (ROM) and/or oxytocin within one hour of admission and/or duration between ROM and oxytocin of less than one hour. Women, labor and maternity unit’s characteristics were compared between the “misuse of AL” and “no misuse of AL” groups by bivariate analysis. To identify the determinants of misuse of AL, a multivariable multilevel logistic regression was performed taking into account the data’s hierarchical structure (first level: women, second level: maternity units). Results Among the 7196 women included, 1524 (21.2%) had a misuse of AL. The determinants of misuse of AL were middle school educational level (reference high school), aOR = 1.21; 95%CI[1.01–1.45], gestational age at delivery ≥41weeks (reference 39–40 weeks), aOR = 1.19; 95%CI[1.00–1.42], cervical dilation ≥6cm at admission (reference <3cm), aOR = 1.39; 95%CI[1.10–1.76], epidural analgesia aOR = 1.63; 95%CI[1.35–1.96], delivery in a private hospital (reference public teaching hospital), aOR = 2.25; 95%CI[1.57–3.23]; and maternity units with <1000 deliveries/year and 1000–1999 deliveries/year (reference ≥3000 deliveries/year), respectively aOR = 1.52; 95%CI[1.11–2.08] and aOR = 1.42; 95%CI[1.05–1.92]. Less than 3% of the variance was explained by women characteristics, and 24.17% by the maternity units’ characteristics. Conclusions In France, one spontaneous laboring woman among five is subject to misuse of AL. The misuse is mostly explained by maternity unit’s characteristics. The determinants identified in this study can be used to implement targeted actions in small and private maternity units.
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Affiliation(s)
- Aude Girault
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics, FHU PREMA, Université de Paris, Paris, France
- Maternité Port Royal, AP-HP, Hôpital Cochin, FHU PREMA, Paris, France
- * E-mail:
| | - Béatrice Blondel
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics, FHU PREMA, Université de Paris, Paris, France
| | - François Goffinet
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics, FHU PREMA, Université de Paris, Paris, France
- Maternité Port Royal, AP-HP, Hôpital Cochin, FHU PREMA, Paris, France
| | - Camille Le Ray
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics, FHU PREMA, Université de Paris, Paris, France
- Maternité Port Royal, AP-HP, Hôpital Cochin, FHU PREMA, Paris, France
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Girault A, Goffinet F, Le Ray C. Reducing neonatal morbidity by discontinuing oxytocin during the active phase of first stage of labor: a multicenter randomized controlled trial STOPOXY. BMC Pregnancy Childbirth 2020; 20:640. [PMID: 33081758 PMCID: PMC7576841 DOI: 10.1186/s12884-020-03331-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/09/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oxytocin is effective in reducing labor duration, but can be associated with fetal and maternal complications such as neonatal acidosis and post-partum hemorrhage. When comparing discontinuing oxytocin in the active phase with continuing oxytocin infusion, previous studies were underpowered to show a reduction in neonatal morbidity. Thus, we aim at evaluating the impact of discontinuing oxytocin during the active phase of the first stage of labor on the neonatal morbidity rate. METHODS STOPOXY is a multicenter, randomized, open-label, controlled trial conducted in 20 maternity units in France. The first participant was recruited January 17th 2020. The trial includes women with a live term (≥37 weeks) singleton, in cephalic presentation, receiving oxytocin before 4 cm, after an induced or spontaneous labor. Women aged < 18 years, with a lack of social security coverage, a scarred uterus, a multiple pregnancy, a fetal congenital malformation, a growth retardation <3rd percentile or an abnormal fetal heart rate at randomization are excluded. Women are randomized before 6 cm when oxytocin is either continued or discontinued. Randomization is stratified by center and parity. The primary outcome, neonatal morbidity is assessed using a composite variable defined by an umbilical arterial pH at birth < 7.10 and/or a base excess > 10 mmol/L and/or umbilical arterial lactates> 7 mmol/L and/or a 5 min Apgar score < 7 and/or admission in neonatal intensive care unit. The primary outcome will be compared between the two groups using a chi-square test with a p-value of 0.05. Secondary outcomes include neonatal complications, duration of active phase, mode of delivery, fetal and maternal complications during labor and delivery, including cesarean delivery rate and postpartum hemorrhage, and birth experience. We aim at including 2475 women based on a reduction in neonatal morbidity from 8% in the control group to 5% in the experimental group, with a power of 80% and an alpha risk of 5%. DISCUSSION Discontinuing oxytocin during the active phase of labor could improve both child health, by reducing moderate to severe neonatal morbidity, and maternal health by reducing cesarean delivery and postpartum hemorrhage rates. TRIAL REGISTRATION Clinical trials NCT03991091 , registered June 19th, 2019.
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Affiliation(s)
- Aude Girault
- Université de Paris, INSERM UMR 1153, Equipe EPOPé, 123 boulevard Port Royal, 75014, Paris, France. .,Maternité Port-Royal, AP-HP, Hôpital Cochin, FHU PREMA, F-75014, Paris, France.
| | - François Goffinet
- Université de Paris, INSERM UMR 1153, Equipe EPOPé, 123 boulevard Port Royal, 75014, Paris, France.,Maternité Port-Royal, AP-HP, Hôpital Cochin, FHU PREMA, F-75014, Paris, France
| | - Camille Le Ray
- Université de Paris, INSERM UMR 1153, Equipe EPOPé, 123 boulevard Port Royal, 75014, Paris, France.,Maternité Port-Royal, AP-HP, Hôpital Cochin, FHU PREMA, F-75014, Paris, France
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Zhang L, Zhang L, Li M, Xi J, Zhang X, Meng Z, Wang Y, Li H, Liu X, Ju F, Lu Y, Tang H, Qin X, Ming Y, Huang R, Li G, Dai H, Zhang R, Qin M, Zhu L, Zhang J. A cluster-randomized field trial to reduce cesarean section rates with a multifaceted intervention in Shanghai, China. BMC Med 2020; 18:27. [PMID: 32054535 PMCID: PMC7020498 DOI: 10.1186/s12916-020-1491-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/07/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cesarean section (CS) rate has risen dramatically and stayed at a very high level in China over the past two to three decades. Given the short- and long-term adverse effects of CS, effective strategies are needed to reduce unnecessary CS. We aimed to evaluate whether a multifaceted intervention would decrease the CS rate in China. METHODS We carried out a cluster-randomized field trial with a multifaceted intervention in Shanghai, China, from 2015 to 2017. A total of 20 hospitals were randomly allocated into an intervention or a control group. The intervention consisted of more targeted health education to pregnant women, improved hospital CS policy, and training of midwives/doulas for 8 months. The study included a baseline survey, the intervention, and an evaluation survey. The primary outcome was the changes of overall CS rate from the pre-intervention to the post-intervention period. A subgroup analysis stratified by the Robson classification was also conducted to examine the CS change among women with various obstetric characteristics. RESULTS A total of 10,752 deliveries were randomly selected from the pre-intervention period and 10,521 from the post-intervention period. The baseline CS rates were 42.5% and 41.5% in the intervention and control groups, respectively, while the post-intervention CS rates were 43.4% and 42.4%, respectively. Compared with the control group, the intervention did not significantly reduce the CS rate (adjusted OR = 0.92; 95% CI 0.73, 1.15). Similar results were obtained in subgroup analyses stratified by the risk level of pregnancy, maternal age, number of previous CS, or parity. Scarred uterus and maternal request remained the primary reasons for CS after the interventions in both groups. The intervention did not alter the perinatal outcomes (adjusted change of risk score = - 0.06; 95%CI - 0.43, 0.31). CONCLUSIONS A multifaceted intervention including more targeted prenatal health education, improved hospital CS policy, and training of midwives/doulas, did not significantly reduce the CS rate in Shanghai, China. However, our experience in implementing a multifaceted intervention may provide useful information to other similar areas with high CS use. TRIAL REGISTRATION This trial was registered at the Chinese Clinical Trial Registry (www.chictr.org.cn) (ChiCTR-IOR-16009041) on 17 August 2016.
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Affiliation(s)
- Lulu Zhang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lin Zhang
- Department of Obstetrics and Gynecology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Meng Li
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Jiao Tong University School of Public Health, Shanghai, China
| | - Jie Xi
- Department of Obstetrics, Jiading District Maternal and Child Health Hospital, Shanghai, China
| | - Xiaohua Zhang
- Department of Maternal Health Care, Minhang District Maternal and Child Health Hospital, Shanghai, China
| | - Zhenni Meng
- Department of Obstetrics, First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ying Wang
- Department of Obstetrics, Songjiang District Maternal and Child Health Hospital, Shanghai, China
| | - Huaping Li
- Department of Obstetrics and Gynecology, Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaohua Liu
- Department of Obstetrics, First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Obstetrics, China Welfare Association International Peace Maternal and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feihua Ju
- Department of Obstetrics and Gynecology, Pudong New District Maternal and Child Health Hospital, Shanghai, China
| | - Yuping Lu
- Department of Obstetrics and Gynecology, Pudong New Area People's Hospital, Shanghai, China
| | - Huijun Tang
- Department of Obstetrics, Putuo District Maternal and Child Health Hospital, Shanghai, China
| | - Xianju Qin
- Department of General Surgery, Eighth People's Hospital, Shanghai, China
| | - Yanhong Ming
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rong Huang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guohong Li
- Shanghai Jiao Tong University School of Public Health, Shanghai, China.,Center for HTA, China Hospital Development Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Hongying Dai
- Nursing College, Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - Rong Zhang
- Shanghai Maternal and Child Health Center, Shanghai, China
| | - Min Qin
- Shanghai Maternal and Child Health Center, Shanghai, China.
| | - Liping Zhu
- Shanghai Maternal and Child Health Center, Shanghai, China.
| | - Jun Zhang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Begley K, Daly D, Panda S, Begley C. Shared decision-making in maternity care: Acknowledging and overcoming epistemic defeaters. J Eval Clin Pract 2019; 25:1113-1120. [PMID: 31338953 PMCID: PMC6899916 DOI: 10.1111/jep.13243] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 05/26/2019] [Accepted: 07/05/2019] [Indexed: 11/29/2022]
Abstract
Shared decision-making involves health professionals and patients/clients working together to achieve true person-centred health care. However, this goal is infrequently realized, and most barriers are unknown. Discussion between philosophers, clinicians, and researchers can assist in confronting the epistemic and moral basis of health care, with benefits to all. The aim of this paper is to describe what shared decision-making is, discuss its necessary conditions, and develop a definition that can be used in practice to support excellence in maternity care. Discussion between the authors, with backgrounds in philosophy, clinical maternity care, health care management, and maternity care research, assisted the team to confront established norms in maternity care and challenge the epistemic and moral basis of decision-making for caesarean section. The team concluded that shared decision-making must start in pregnancy and continue throughout labour and birth, with equality in discourse facilitated by the clinician. Clinicians have a duty of care for the adequacy of women's knowledge, which can only be fulfilled when relevant knowledge is offered freely and when personal beliefs and biases that may impinge on decision-making (defeaters) are disclosed. Informed consent is not shared decision-making. Key barriers include existing cultural norms of "the doctor knows best" and "patient acquiescence" that prevent defeaters being acknowledged and discussed and can lead to legal challenges, overuse of medical intervention and, in some areas, obstetric violence. Shared decision-making in maternity care can thus be defined as an enquiry by clinician and expectant woman aimed at deciding upon a course of care or none, which takes the form of a dialogue within which the clinician fulfils their duty of care to the client's knowledge by making available their complete knowledge (based on all types of evidence) and expertise, including an exposition of any relevant and recognized potential defeaters. Research to develop measurement tools is required.
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Affiliation(s)
- Keith Begley
- Department of Philosophy, Trinity College Dublin, Dublin, Ireland
| | - Deirdre Daly
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Sunita Panda
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Cecily Begley
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
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Lorentzen I, Andersen CS, Jensen HS, Fogsgaard A, Foureur M, Lauszus FF, Nohr EA. Study protocol for a randomised trial evaluating the effect of a "birth environment room" versus a standard labour room on birth outcomes and the birth experience. Contemp Clin Trials Commun 2019; 14:100336. [PMID: 30886935 PMCID: PMC6402376 DOI: 10.1016/j.conctc.2019.100336] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 01/23/2019] [Accepted: 02/13/2019] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION In the last decade, there has been an increased interest in exploring the impact of the physical birth environment on birth outcomes. The birth environment might have an important role in facilitating the production of the hormone oxytocin that causes contractions during labour. Oxytocin is released in a safe, secure and confidence-inducing environment, and environments focused on technology and medical interventions to achieve birth may disrupt the production of oxytocin and slow down the progress of labour. An experimental "birth environment room" was designed, inspired by knowledge from evidence-based healthcare design, which advocates bringing nature into the room to reduce stress. The purpose is to examine whether the 'birth environment room', with its design and decor to minimise stress, has an impact on birth outcomes and the birth experience of the woman and her partner. MATERIALS AND METHODS A randomised controlled trial will recruit 680 nulliparous women at term who will be randomly allocated to either the "birth environment room" or a standard room. The study will take place at the Department of Obstetrics and Gynecology at Herning Hospital, with recruitment from May 2015. Randomisation to either the "birth environment room" or standard room takes place just before admission to a birth room during labour. The primary outcome is augmentation of labour, and the study has 80% power to detect a 10% difference between the two groups (two-sided α = 0.05). Secondary outcomes are duration of labour, use of pharmacological pain relief, mode of birth, and rating of the birth experience by women and their partners. TRIAL REGISTRATION NCT02478385(10/08/2016).
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Affiliation(s)
- Iben Lorentzen
- Department of Gynecology and Obstetrics, Gl. Landevej 61, 7400 Herning, Denmark
| | | | | | - Ann Fogsgaard
- Department of Gynecology and Obstetrics, Gl. Landevej 61, 7400 Herning, Denmark
| | - Maralyn Foureur
- Centre for Midwifery, Child and Family Health, University of Technology Sydney, Level 11, Room 109, Building 10, City Campus, PO Box 123 Broadway, Sydney, NSW 2007, Australia
| | - Finn Friis Lauszus
- Department of Gynecology and Obstetrics, Gl. Landevej 61, 7400 Herning, Denmark
| | - Ellen Aagaard Nohr
- Research Unit for Obstetrics and Gynecology, Institute of Clinical Research, University of Southern Denmark, Campusvej 55, 5230 Odense C, Denmark
- Centre of Women's, Family and Child Health, University of South-Eastern Norway, Kongsberg, Norway
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9
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Hoxha I, Braha M, Syrogiannouli L, Goodman DC, Jüni P. Caesarean section in uninsured women in the USA: systematic review and meta-analysis. BMJ Open 2019; 9:e025356. [PMID: 30833323 PMCID: PMC6443081 DOI: 10.1136/bmjopen-2018-025356] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 11/14/2018] [Accepted: 12/19/2018] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE The aim of this study is to assess the odds of caesarean section (CS) for uninsured women in the USA and understand the underlying mechanisms as well as consequences of lower use. STUDY DESIGN Systematic review and meta-analysis. DATA SOURCES PubMed, Embase, the Cochrane Library and CINAHL from the first year of records to April 2018. ELIGIBILITY CRITERIA We included studies that reported data to allow the calculation of ORs of CS of uninsured as compared with insured women. OUTCOMES The prespecified primary outcome was the adjusted OR of deliveries by CS of uninsured women as compared with privately or publicly insured women. The prespecified secondary outcome was the crude OR of deliveries by CS of uninsured women as compared with insured women. RESULTS 12 articles describing 16 separate studies involving more than 8.8 million women were included in this study. We found: 0.70 times lower odds of CS in uninsured as compared with privately insured women (95% CI 0.63 to 0.78), with no relevant heterogeneity between studies (τ2=0.01); and 0.92 times lower odds for CS in uninsured as compared with publicly insured women (95% CI 0.80 to 1.07), with no relevant heterogeneity between studies (τ2=0.02). We found 0.70 times lower odds in uninsured as compared with privately and publicly insured women (95% CI 0.69 to 0.72). CONCLUSIONS CSs are less likely to be performed in uninsured women as compared with insured women. While the higher rates for CS among privately insured women can be explained with financial incentives associated with private insurance, the lower odds among uninsured women draw attention at barriers to access for delivery care. In many regions, the rates for uninsured women are above, close or below the benchmarks for appropriate CS rates and could imply both, underuse and overuse.
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Affiliation(s)
- Ilir Hoxha
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth Hanover, New Hampshire, USA
- Heimerer College, Prishtina, Kosovo
| | - Medina Braha
- International Business College Mitrovica, Mitrovica, Kosovo
| | | | - David C Goodman
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, USA
| | - Peter Jüni
- Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Department of Medicine, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Chen I, Opiyo N, Tavender E, Mortazhejri S, Rader T, Petkovic J, Yogasingam S, Taljaard M, Agarwal S, Laopaiboon M, Wasiak J, Khunpradit S, Lumbiganon P, Gruen RL, Betran AP. Non-clinical interventions for reducing unnecessary caesarean section. Cochrane Database Syst Rev 2018; 9:CD005528. [PMID: 30264405 PMCID: PMC6513634 DOI: 10.1002/14651858.cd005528.pub3] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Caesarean section rates are increasing globally. The factors contributing to this increase are complex, and identifying interventions to address them is challenging. Non-clinical interventions are applied independently of a clinical encounter between a health provider and a patient. Such interventions may target women, health professionals or organisations. They address the determinants of caesarean births and could have a role in reducing unnecessary caesarean sections. This review was first published in 2011. This review update will inform a new WHO guideline, and the scope of the update was informed by WHO's Guideline Development Group for this guideline. OBJECTIVES To evaluate the effectiveness and safety of non-clinical interventions intended to reduce unnecessary caesarean section. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers in March 2018. We also searched websites of relevant organisations and reference lists of related reviews. SELECTION CRITERIA Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series studies and repeated measures studies were eligible for inclusion. The primary outcome measures were: caesarean section, spontaneous vaginal birth and instrumental birth. DATA COLLECTION AND ANALYSIS We followed standard methodological procedures recommended by Cochrane. We narratively described results of individual studies (drawing summarised evidence from single studies assessing distinct interventions). MAIN RESULTS We included 29 studies in this review (19 randomised trials, 1 controlled before-after study and 9 interrupted time series studies). Most of the studies (20 studies) were conducted in high-income countries and none took place in low-income countries. The studies enrolled a mixed population of pregnant women, including nulliparous women, multiparous women, women with a fear of childbirth, women with high levels of anxiety and women having undergone a previous caesarean section.Overall, we found low-, moderate- or high-certainty evidence that the following interventions have a beneficial effect on at least one primary outcome measure and no moderate- or high-certainty evidence of adverse effects.Interventions targeted at women or familiesChildbirth training workshops for mothers alone may reduce caesarean section (risk ratio (RR) 0.55, 95% confidence interval (CI) 0.33 to 0.89) and may increase spontaneous vaginal birth (RR 2.25, 95% CI 1.16 to 4.36). Childbirth training workshops for couples may reduce caesarean section (RR 0.59, 95% CI 0.37 to 0.94) and may increase spontaneous vaginal birth (RR 2.13, 95% CI 1.09 to 4.16). We judged this one study with 60 participants to have low-certainty evidence for the outcomes above.Nurse-led applied relaxation training programmes (RR 0.22, 95% CI 0.11 to 0.43; 104 participants, low-certainty evidence) and psychosocial couple-based prevention programmes (RR 0.53, 95% CI 0.32 to 0.90; 147 participants, low-certainty evidence) may reduce caesarean section. Psychoeducation may increase spontaneous vaginal birth (RR 1.33, 95% CI 1.11 to 1.61; 371 participants, low-certainty evidence). The control group received routine maternity care in all studies.There were insufficient data on the effect of the four interventions on maternal and neonatal mortality or morbidity.Interventions targeted at healthcare professionalsImplementation of clinical practice guidelines combined with mandatory second opinion for caesarean section indication slightly reduces the risk of overall caesarean section (mean difference in rate change -1.9%, 95% CI -3.8 to -0.1; 149,223 participants). Implementation of clinical practice guidelines combined with audit and feedback also slightly reduces the risk of caesarean section (risk difference (RD) -1.8%, 95% CI -3.8 to -0.2; 105,351 participants). Physician education by local opinion leader (obstetrician-gynaecologist) reduced the risk of elective caesarean section to 53.7% from 66.8% (opinion leader education: 53.7%, 95% CI 46.5 to 61.0%; control: 66.8%, 95% CI 61.7 to 72.0%; 2496 participants). Healthcare professionals in the control groups received routine care in the studies. There was little or no difference in maternal and neonatal mortality or morbidity between study groups. We judged the certainty of evidence to be high.Interventions targeted at healthcare organisations or facilitiesCollaborative midwifery-labourist care (in which the obstetrician provides in-house labour and delivery coverage, 24 hours a day, without competing clinical duties), versus a private practice model of care, may reduce the primary caesarean section rate. In one interrupted time series study, the caesarean section rate decreased by 7% in the year after the intervention, and by 1.7% per year thereafter (1722 participants); the vaginal birth rate after caesarean section increased from 13.3% before to 22.4% after the intervention (684 participants). Maternal and neonatal mortality were not reported. We judged the certainty of evidence to be low.We studied the following interventions, and they either made little or no difference to caesarean section rates or had uncertain effects.Moderate-certainty evidence suggests little or no difference in caesarean section rates between usual care and: antenatal education programmes for physiologic childbirth; antenatal education on natural childbirth preparation with training in breathing and relaxation techniques; computer-based decision aids; individualised prenatal education and support programmes (versus written information in pamphlet).Low-certainty evidence suggests little or no difference in caesarean section rates between usual care and: psychoeducation; pelvic floor muscle training exercises with telephone follow-up (versus pelvic floor muscle training without telephone follow-up); intensive group therapy (cognitive behavioural therapy and childbirth psychotherapy); education of public health nurses on childbirth classes; role play (versus standard education using lectures); interactive decision aids (versus educational brochures); labourist model of obstetric care (versus traditional model of obstetric care).We are very uncertain as to the effect of other interventions identified on caesarean section rates as the certainty of the evidence is very low. AUTHORS' CONCLUSIONS We evaluated a wide range of non-clinical interventions to reduce unnecessary caesarean section, mostly in high-income settings. Few interventions with moderate- or high-certainty evidence, mainly targeting healthcare professionals (implementation of guidelines combined with mandatory second opinion, implementation of guidelines combined with audit and feedback, physician education by local opinion leader) have been shown to safely reduce caesarean section rates. There are uncertainties in existing evidence related to very-low or low-certainty evidence, applicability of interventions and lack of studies, particularly around interventions targeted at women or families and healthcare organisations or facilities.
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Affiliation(s)
- Innie Chen
- University of OttawaDepartment of Obstetrics & GynecologyOttawaONCanada
| | - Newton Opiyo
- CochraneCochrane Editorial UnitSt Albans House, 57‐59 HaymarketLondonUKSW1Y 4QX
| | - Emma Tavender
- Monash UniversityAustralian Satellite of the Cochrane EPOC Group, School of Public Health and Preventative MedicineMelbourneVictoriaAustraliaVIC 3004
| | | | - Tamara Rader
- Canadian Agency for Drugs and Technologies in Health (CADTH)600‐865 Carling AvenueOttawaONCanada
| | - Jennifer Petkovic
- University of OttawaBruyère Research Institute43 Bruyère StAnnex E, room 312OttawaONCanadaK1N 5C8
| | | | - Monica Taljaard
- Ottawa Hospital Research InstituteClinical Epidemiology ProgramThe Ottawa Hospital ‐ Civic Campus1053 Carling Ave, Box 693OttawaONCanadaK1Y 4E9
| | | | - Malinee Laopaiboon
- Khon Kaen UniversityDepartment of Epidemiology and Biostatistics, Faculty of Public Health123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
| | - Jason Wasiak
- Austin Health; The University of MelbourneOlivia Newton John Cancer Research Institute; Department of PaediatricsMelbourneVictoriaAustralia
- University of MelbourneDepartment of PediatricsMelbourneVictoriaAustralia
| | - Suthit Khunpradit
- Lamphun HospitalDepartment of Obstetrics and Gynaecology177 Jamthevee RoadLamphunLamphunThailand51000
| | - Pisake Lumbiganon
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
| | - Russell L Gruen
- Nanyang Technological UniversityLee Kong Chian School of Medicine11 Mandalay RoadSingaporeSingapore308232
| | - Ana Pilar Betran
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and ResearchGenevaSwitzerland
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11
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Côrtes CT, de Oliveira SMJV, dos Santos RCS, Francisco AA, Riesco MLG, Shimoda GT. Implementation of evidence-based practices in normal delivery care. Rev Lat Am Enfermagem 2018; 26:e2988. [PMID: 29538583 PMCID: PMC5863276 DOI: 10.1590/1518-8345.2177.2988] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 11/07/2017] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE to evaluate the impact of the implementation of evidence-based practices on normal delivery care. METHOD quasi-experimental, before-and-after intervention study conducted in a public maternity hospital, Amapá. Forty-two professionals and 280 puerperal women were interviewed and data from 555 medical records were analyzed. The study was developed in three phases: baseline audit (phase 1), educational intervention (phase 2) and post-intervention audit (phase 3). RESULTS after the intervention, there was an increase of 5.3 percentage points (p.p.) in the normal delivery rate. Interviews with the women revealed a significant increase of the presence of companions during labor (10.0 p.p.) and of adoption of the upright or squatting position (31.4 p.p.); significant reduction of amniotomy (16.8 p.p.), lithotomy position (24.3 p.p.), and intravenous oxytocin (17.1 p.p.). From the professionals' perspective, there was a statistical reduction in the prescription/administration of oxytocin (29.6 p.p.). In the analysis of medical records, a significant reduction in the rate of amniotomy (29.5 p.p.) and lithotomy position (1.5 p.p.) was observed; the rate of adoption of the upright or squatting position presented a statistical increase of 2.2 p.p. CONCLUSIONS there was a positive impact of the educational intervention on the improvement of parturition assistance, but the implementation process was not completely successful in the adoption of scientific evidence in normal delivery care in this institution.
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Affiliation(s)
- Clodoaldo Tentes Côrtes
- Doctoral student, Escola de Enfermagem, Universidade de São Paulo, São
Paulo, SP, Brazil. Assistant Professor, Departamento de Ciências Biológicas e da Saúde,
Universidade Federal do Amapá, Macapá, Amapá, Brazil
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12
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Liang J, Mu Y, Li X, Tang W, Wang Y, Liu Z, Huang X, Scherpbier RW, Guo S, Li M, Dai L, Deng K, Deng C, Li Q, Kang L, Zhu J, Ronsmans C. Relaxation of the one child policy and trends in caesarean section rates and birth outcomes in China between 2012 and 2016: observational study of nearly seven million health facility births. BMJ 2018; 360:k817. [PMID: 29506980 PMCID: PMC5836714 DOI: 10.1136/bmj.k817] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To examine how the relaxation of the one child policy and policies to reduce caesarean section rates might have affected trends over time in caesarean section rates and perinatal and pregnancy related mortality in China. DESIGN Observational study. SETTING China's National Maternal Near Miss Surveillance System (NMNMSS). PARTICIPANTS 6 838 582 births at 28 completed weeks or more of gestation or birth weight ≥1000 g in 438 hospitals in the NMNMSS between 2012 and 2016. MAIN OUTCOME MEASURES Obstetric risk was defined using a modified Robson classification. The main outcome measures were changes in parity and age distributions and relative frequency of each Robson group, crude and adjusted trends over time in caesarean section rates within each risk category (using Poisson regression with a robust variance estimator), and trends in perinatal and pregnancy related mortality over time. RESULTS Caesarean section rates declined steadily between 2012 and 2016 (crude relative risk 0.91, 95% confidence interval 0.89 to 0.93), reaching an overall hospital based rate of 41.1% in 2016. The relaxation of the one child policy was associated with an increase in the proportion of multiparous births (from 34.1% in 2012 to 46.7% in 2016), and births in women with a uterine scar nearly doubled (from 9.8% to 17.7% of all births). Taking account of these changes, the decline in caesarean sections was amplified over time (adjusted relative risk 0.82, 95% confidence interval 0.81 to 0.84). Caesarean sections declined noticeably in nulliparous women (0.75, 0.73 to 0.77) but also declined in multiparous women without a uterine scar (0.65, 0.62 to 0.77). The decrease in caesarean section rates was most pronounced in hospitals with the highest rates in 2012, consistent with the government's policy of targeting hospitals with the highest rates. Perinatal mortality declined from 10.1 to 7.2 per 1000 births over the same period (0.87, 0.83 to 0.91), and there was no change in pregnancy related mortality over time. CONCLUSIONS China is the only country that has succeeded in reverting the rising trends in caesarean sections. China's success is remarkable given that the changes in obstetric risk associated with the relaxation of the one child policy would have led to an increase in the need for caesarean sections. China's experience suggests that change is possible when strategies are comprehensive and deal with the system level factors that underpin overuse as well as the various incentives at work during a clinical encounter.
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Affiliation(s)
- Juan Liang
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yi Mu
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiaohong Li
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wen Tang
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yanping Wang
- National Office for Maternal and Child Health Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zheng Liu
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiaona Huang
- Health, Nutrition and Water, Sanitation & Hygiene, UNICEF China, Beijing, China
| | - Robert W Scherpbier
- Health, Nutrition and Water, Sanitation & Hygiene, UNICEF China, Beijing, China
| | - Sufang Guo
- UNICEF Regional Office for South Asia, Kathmandu, Nepal
| | - Mingrong Li
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li Dai
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Kui Deng
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Changfei Deng
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qi Li
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Leni Kang
- National Office for Maternal and Child Health Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jun Zhu
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Carine Ronsmans
- West China School of Public Health, Sichuan University, Chengdu, Sichuan, China
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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13
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Rossen J, Lucovnik M, Eggebø TM, Tul N, Murphy M, Vistad I, Robson M. A method to assess obstetric outcomes using the 10-Group Classification System: a quantitative descriptive study. BMJ Open 2017; 7:e016192. [PMID: 28706102 PMCID: PMC5726112 DOI: 10.1136/bmjopen-2017-016192] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Internationally, the 10-Group Classification System (TGCS) has been used to report caesarean section rates, but analysis of other outcomes is also recommended. We now aim to present the TGCS as a method to assess outcomes of labour and delivery using routine collection of perinatal information. DESIGN This research is a methodological study to describe the use of the TGCS. SETTING Stavanger University Hospital (SUH), Norway, National Maternity Hospital Dublin, Ireland and Slovenian National Perinatal Database (SLO), Slovenia. PARTICIPANTS 9848 women from SUH, Norway, 9250 women from National Maternity Hospital Dublin, Ireland and 106 167 women, from SLO, Slovenia. MAIN OUTCOME MEASURES All women were classified according to the TGCS within which caesarean section, oxytocin augmentation, epidural analgesia, operative vaginal deliveries, episiotomy, sphincter rupture, postpartum haemorrhage, blood transfusion, maternal age >35 years, body mass index >30, Apgar score, umbilical cord pH, hypoxic-ischaemic encephalopathy, antepartum and perinatal deaths were incorporated. RESULTS There were significant differences in the sizes of the groups of women and the incidences of events and outcomes within the TGCS between the three perinatal databases. CONCLUSIONS The TGCS is a standardised objective classification system where events and outcomes of labour and delivery can be incorporated. Obstetric core events and outcomes should be agreed and defined to set standards of care. This method provides continuous and available observations from delivery wards, possibly used for further interpretation, questions and international comparisons. The definition of quality may vary in different units and can only be ascertained when all the necessary information is available and considered together.
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Affiliation(s)
- Janne Rossen
- Department of Obstetrics and Gynecology, Sørlandet Hospital HF Kristiansand, Kristiansand, Norway
- Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and Technology, Trondheim, Norway
| | - Miha Lucovnik
- Department of Perinatology, Division of Obstetrics and Gynecology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Torbjørn Moe Eggebø
- Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Obstetrics and Gynecology, Stavanger University Hospital, Stavanger, Norway
- National Center for Fetal Medicine, Trondheim University Hospital, St Olavs Hospital, Trondheim, Norway
| | - Natasa Tul
- Department of Perinatology, Division of Obstetrics and Gynecology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Ingvild Vistad
- Department of Obstetrics and Gynecology, Sørlandet Hospital HF Kristiansand, Kristiansand, Norway
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14
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Rygh AB, Skjeldestad FE, Körner H, Eggebø TM. Assessing the association of oxytocin augmentation with obstetric anal sphincter injury in nulliparous women: a population-based, case-control study. BMJ Open 2014; 4:e004592. [PMID: 25059967 PMCID: PMC4120359 DOI: 10.1136/bmjopen-2013-004592] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess the association of oxytocin augmentation with obstetric anal sphincter injury among nulliparous women. DESIGN Population-based, case-control study. SETTING Primary and secondary teaching hospital serving a Norwegian region. POPULATION 15 476 nulliparous women with spontaneous start of labour, single cephalic presentation and gestation ≥37 weeks delivering vaginally between 1999 and 2012. METHODS Based on the presence or absence of oxytocin augmentation, episiotomy, operative vaginal delivery and birth weight (<4000 vs ≥4000 g), we modelled in logistic regression the best fit for prediction of anal sphincter injury. Within the modified model of main exposures, we tested for possible confounding, and interactions between maternal age, ethnicity, occiput posterior position and epidural analgaesia. MAIN OUTCOME MEASURE Obstetric anal sphincter injury. RESULTS Oxytocin augmentation was associated with a higher OR of obstetric anal sphincter injuries in women giving spontaneous birth to infants weighing <4000 g (OR 1.8; 95% CI 1.5 to 2.2). Episiotomy was not associated with sphincter injuries in spontaneous births, but with a lower OR in operative vaginal deliveries. Spontaneous delivery of infants weighing ≥4000 g was associated with a threefold higher OR, and epidural analgaesia was associated with a 30% lower OR in comparison to no epidural analgaesia. CONCLUSIONS Oxytocin augmentation was associated with a higher OR of obstetric anal sphincter injuries during spontaneous deliveries of normal-size infants. We observed a considerable effect modification between the most important factors predicting anal sphincter injuries in the active second stage of labour.
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Affiliation(s)
- Astrid B Rygh
- Department of Obstetrics and Gynecology, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine I, University of Bergen, Bergen, Norway
| | - Finn Egil Skjeldestad
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Hartwig Körner
- Department of Clinical Medicine I, University of Bergen, Bergen, Norway
- Department of GI Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Torbjørn M Eggebø
- Department of Obstetrics and Gynecology, Stavanger University Hospital, Stavanger, Norway
- National Center for Fetal Medicine, Trondheim University Hospital (St Olavs Hospital), Trondheim, Norway
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