Fundal pressure during the second stage of labour

Is an episiotomy always necessary during an operative vaginal delivery with vacuum? A longitudinal study

Objective: The use of episiotomy during operative vaginal birth (OVB) is rather debated among operators and in literature. It is also important to evaluate the indications for which episiotomy is performed. In fact, the consequences of an episiotomy can be invalidating for patients with long-lasting results. The aim of this study is the evaluation of the role of episiotomy during OVB with the vacuum extractor and its correlation with Obstetric Anal Sphincter Injuries (OASIs).Methods: On of 9165 vaginal births, a total of 498 OVB (5.4%) were enrolled in a longitudinal prospective observational study. The incidence of OASIs was evaluated in our population after OVB performed with the vacuum extractor, during which the execution of episiotomy was performed indicated by clinician in charge.Results: OASIs occurred in 4% of the patients (n = 20). Episiotomy was performed in 39% of them (n = 181). OASIs incidence was 6% (n = 17) in the No Episiotomy and 1.8% (n = 3) in Episiotomy group (p<.001). Performance of episiotomy during OVB determined a protective effect against OASIs (p = 0.025 in full cohort and p = 0.013 in the primiparous group). An expulsive phase under one hour was an almost significant protective factor (p = 0.052).Conclusions: The use of episiotomy during OVB was associated with much lower OASIs rates in nulliparous women with a vacuum extraction; OR 0.23 (CI 95% 0.07-0.81) p = 0.037 in nulliparous women and the number necessary to treat was 18 among nulliparous women to prevent 1 OASIs. A further risk factor that emerged from the analysis is a prolonged expulsive period, whereas fundal pressure does not seem to have a statistically significant influence.

Measuring disrespect and abuse during childbirth in a high-resource country: Development and validation of a German self-report tool

INTRODUCTION

Increasing evidence on disrespect and abuse during childbirth has led to growing concern about the quality of care childbearing women are experiencing. To provide quantitative evidence of disrespect and abuse during childbirth services in Germany a validated measurement tool is needed.

RESEARCH AIM

The aim of this research project was the development and psychometric validation of a survey tool in the German language that measures disrespect and abuse of women during childbirth.

METHODS

A survey tool was created including the following measures: German adaptations of the short and long form of the "Mothers on Respect" (MOR) index (MOR-7 and MOR-G); the "Mothers' Autonomy in Decision Making" (MADM) scale; a mistreatment-index (MIST-I) comprising indicators of mistreatment during childbirth; and a set of items that measure experiences of discrimination during maternity care. Internal consistency reliability and construct validity of the scales were assessed using Cronbach's alpha, unweighted least squares factor analysis and non-parametric correlation analysis with a scale that measures a related construct, the Posttraumatic Symptom Scale - Self Report (PSS-SR) scale. We distributed the survey online, recruiting through snowball sampling via social media. A selection bias towards women who had experienced disrespect and abuse during their birth was intended and expedient for tool validation. The final sample of participants (n = 2045) had given birth in Germany between 2009 and 2018.

FINDINGS

More than 77% of the study participants reported at least one form of mistreatment with non-consented care being the most commonly reported type of mistreatment, followed by physical violence, violation of physical privacy, verbal abuse and neglect. All included scales showed good psychometric properties with high Cronbach's alphas (0.95 for both MOR versions and 0.96 for MADM). Factor analysis generated one factor scales with high factor loadings (0.75 to 0.92 for MOR-7; 0.37 to 0.90 for MOR-G and 0.83 to 0.92 for MADM). MOR-7, MOR-G, MADM and MIST-I scores were significantly (p<0.001) correlated with PSS-SR scores (Spearman's rho -0.70, -0.61 and 0.68 for MOR-G, MADM and the MIST-I, respectively).

CONCLUSIONS

This study presents a valid and reliable instrument for the quantitative assessment of disrespect and abuse during childbirth in Germany. Childbearing women's experiences of disrespect and abuse are a relevant phenomenon in German hospital based maternity care. Disrespect and abuse during childbirth appear to contribute to post-traumatic symptoms and may be associated with severe mental health problems postpartum.

Fundal pressure to shorten the second stage of labor: Systematic review and meta-analysis

OBJECTIVES

Systematically review the evidence on fundal pressure to expedite vaginal delivery.

STUDY DESIGN

Literature search in electronic databases. Randomized controlled trials of fundal pressure to expedite delivery were included in this systematic review and meta-analysis. The primary outcome was the length of the second stage.

RESULTS

We identified 10 randomized controlled trials. Fundal pressure was associated with a shorter length of the second stage of labor (mean difference (MD) -20.33 min, 95% confidence intervals (CI) -28.55, -12.11). Sub-group analysis with only manual pressure or a belt confirmed the association. There was no significant difference in the rate of vaginal delivery (relative risk (RR) 1.00, 95%, CI 0.98, 1.02), one and five minute Apgar scores (MD 0.10, 95%, confidence intervals -0.05, 0.24; and MD 0.02, 95%, CI -0.12, 0.15), neonatal trauma (RR 0.33, 95%, CI 0.01, 7.90), vaginal/perineal laceration (RR 0.83, 95%, CI 0.57, 1.22), cervical laceration (RR 1.30, 95%, CI 0.21, 8.02), episiotomy (RR 1.08, 95%, CI 0.96, 1.21), cesarean section rate (RR 0.72; 95%, CI 0.34, 1.51), operative vaginal deliveries (RR 0.79; 95%, CI 0.55, 1.13) and neonatal intensive care admissions (RR 0.33, 95%, CI 0.01, 7.90). However, patients receiving fundal pressure had a lower umbilical cord arterial pH (MD -0.03, 95%, CI -0.04, -0.01), and a 3.5 non-significantly higher incidence of Apgar scores < 7 at 5 min (4.9% vs 0.7%, RR 3.48, 95%, CI 0.57, 21.32).

CONCLUSIONS

Fundal pressure in the second stage is associated with a 20-minute decrease in the length of labor and a small decrease in neonatal umbilical artery pH.

TheMidwifery Student’s Observations about the Implementation of International Guidelines and Protocols in Greek Maternity Hospitals

Background: Childbirth is a unique experience ina woman’s life and always remains indelibly engraved in her memory. For this reason, it is necessary to ensure appropriate conditions to have a positive birth experience. Thus, guidelines and protocols have been developed by major international organizations that aim to promote normal labor and better care for the mother and fetus without unnecessary interventions. The aim of this study is to investigate whether the international guidelines and protocols are observed in Greek maternity hospitals. Methods: The study involved 124 male and female students from the three departments of Midwifery: University of West Attica, International Hellenic University and University Western Macedonia, which completed an equal number of self-report questionnaires with their socio-demographic data and were then asked to answer questions posed by instructions for normal childbirth. Results: It was observed that many of the guidelines are not followed, such as grooming and enema, prohibition of feeding and fluid intake, application of pressure on the bottom of the uterus, frequent vaginal examination, prohibition in the presence of sessions, continuous cardiotocographic follow-up in low-risk pregnancies, termination of delivery only in a supine gynecological position, routine perineotomy and immediate ligation of the umbilical cord. Conclusions: The purpose of the guidelines is to maintain the natural course of childbirth by avoiding a series of unnecessary acts that alter the naturalness and undermine the rights of women in childbirth.

The reproductive potential of uterus transplantation: future prospects

BACKGROUND AND AIM

Absolute uterine factor infertility (AUFI) is a form of infertility whereby conception and/or maintenance of pregnancy is impossible as a result of uterine absence or its completed dysfunction. It affects 1/500 women of reproductive age while the incidence is about 8% of infertile couples. Uterus transplantation (UTx) has been gaining ground as a viable option to enable women with AUFI to have biological children and as an alternative to surrogacy, a highly controversial practice still banned in many countries.

METHODS

The authors have set out to strike a reasonable balance between UTx benefits and the still numerous risks, whether clinical or ethical, associated with such an innovative form of transplant, which is not life-saving, requires immunosuppression throughout pregnancy and the organ to be removed right after childbirth.

RESULTS

While still far from achieving mainstream status, considerable strides have been made in UTx outcomes, with many live births already recorded. Procedures from living donor are reportedly more effective in terms of success rates. Organ tissue engineering has been explored and developed with promising results.

CONCLUSIONS

UTx entails various risks and ethical quandaries which have to do with reproductive autonomy and rights. New human attempts and clinical trials of UTx should be performed to further optimize the procedure in relation to safety and effectiveness. Techniques such as tissue engineering could lead in the medium-long term to a wholly bioengineered uterus to be used for transplantation, relying on scaffolds from decellularized organs or tissues that can be recellularized by several types of autologous somatic/stem cells. Such advances hold promise in terms of solving UTx-related complications and organ supply difficulties.

Risk Factors for Cerebral Palsy in Moldova

Background and Objectives: This is the first study assessing risk factors for cerebral palsy (CP) among children born in Moldova. The aim of this study was to identify and describe risk factors for cerebral palsy (CP) among children born in Moldova, which is one of the low-middle income countries in Europe. Materials and Methods: We identified 351 children with CP born during 2009 and 2010 in Moldova. Detailed information on 417 children without CP served as a reference group. Logistic regression analyses were applied to the calculate crude and adjusted odds ratios (OR) for CP with 95% confidence intervals (CI) in addition to attributable fraction (AF). Results: Among children with CP (40.5% girls), 26% had spastic unilateral, 54% bilateral, 13% dyskinetic, 5% ataxic and 2% unclassified CP. Significant risk factors for CP included maternal alcohol consumption during pregnancy (OR 1.7, p = 0.002), maternal hypertension (OR 2.0, p < 0.001), children born to mothers from the rural areas (OR 1.6, p < 0.001), maternal age ≥35 years (OR 0.6, p = 0.018), maternal epilepsy (OR 4.3, p < 0.001), breech delivery (OR 3.1, p = 0.001), home births (OR 6.3, p = 0.001), umbilical cord around neck (OR 2.2, p < 0.001), AVD (OR 3.1, p < 0.001), male gender (OR 1.3, p < 0.001), SGA (OR 1.3, p = 0.027), multiple gestations (OR 1.7, p < 0.001) and hyperbilirubinemia (OR 4.5, p < 0.001). Multivariable analyses showed that the AF of CP was 64% for rural residence (OR 2.8, p = 0.002), 87% for home birth (7.6, p = 0.005), 79% for pre-labor rupture of membrane (OR 4.9, p = 0.001), 66% for breech delivery (OR 2.9, p = 0.002) and 81% for hyperbilirubinemia (OR 5.4, p < 0.001). Conclusions: A combination of factors related to the mother, the delivery and the child were risk factors for CP in Moldova, many of them possibly avoidable. Improved pregnancy and maternity care would potentially reduce the risk of CP. A national CP registry in Moldova is suggested as an opportunity to follow up on these findings.

The prevalence of uterine fundal pressure during the second stage of labour for women giving birth in health facilities: a systematic review and meta-analysis

BACKGROUND

Uterine fundal pressure involves a birth attendant pushing on the woman's uterine fundus to assist vaginal birth. It is used in some clinical settings, though guidelines recommend against it. This systematic review aimed to determine the prevalence of uterine fundal pressure during the second stage of labour for women giving birth vaginally at health facilities.

METHODS

The population of interest were women who experienced labour in a health facility and in whom vaginal birth was anticipated. The primary outcome was the use of fundal pressure during second stage of labour. MEDLINE, EMBASE, CINAHL and Global Index Medicus databases were searched for eligible studies published from 1 January 2000 onwards. Meta-analysis was conducted to determine a pooled prevalence, with subgroup analyses to explore heterogeneity.

RESULTS

Eighty data sets from 76 studies (n = 898,544 women) were included, reporting data from 22 countries. The prevalence of fundal pressure ranged from 0.6% to 69.2% between studies, with a pooled prevalence of 23.2% (95% CI 19.4-27.0, I2 = 99.97%). There were significant differences in prevalence between country income level (p < 0.001, prevalence highest in lower-middle income countries) and method of measuring use of fundal pressure (p = 0.001, prevalence highest in studies that measured fundal pressure based on women's self-report).

CONCLUSIONS

The use of uterine fundal pressure on women during vaginal birth in health facilities is widespread. Efforts to prevent this potentially unnecessary and harmful practice are needed.

FIGO good clinical practice paper: management of the second stage of labor

This good clinical practice paper provides an overview of the current evidence around second stage care, highlighting the challenges and the importance of maintaining high-quality, safe, and respectful care in all settings. It includes a series of recommendations based on best available evidence regarding length of second stage, judicious use of episiotomy, and the importance of competent attendants and adequate resource to facilitate all aspects of second stage management, from physiological birth to assisted vaginal delivery and cesarean at full dilatation. The second stage of labor is potentially the most dangerous time for the baby and can have significant consequences for the mother, including death or severe perineal trauma or fistula, especially where there are failures to recognize and repair. This paper sets out principles of care, including the vital role of skilled birth attendants and birth companions, and the importance of obstetricians and midwives working together effectively and speaking with one voice, whether to women or to policy makers. The optimization of high-quality, safe, and personalized care in the second stage of labor for all women globally can only be achieved by appropriate attention to the training of birth attendants, midwives, and obstetricians. FIGO is committed to this aim alongside the WHO, ICM, and all FIGO's 132 member societies.

Obstetric Violence in Spain (Part II): Interventionism and Medicalization during Birth

BACKGROUND

obstetric violence can partially be represented by the high number of interventions and medicalization rates during the birthing process. The objective of the present study was to determine the interventionism and medicalization levels during childbirth in Spain.

METHODS

a descriptive, retrospective, and cross-sectional study was conducted between January 2018 and June 2019.

RESULTS

the intervention percentages were 34.2% for Kristeller maneuver and 39.3% for episiotomy. Differences appeared in public, private, and mixed healthcare settings (p < 0.001). The mean satisfaction, with healthcare in the different settings, was estimated at 6.88 points (SD ± 2.146) in public healthcare, 4.76 points (SD ± 3.968) in private healthcare, and 8.03 points (SD ± 1.930) in mixed healthcare (p < 0.001). No statistically significant differences were found in Spanish autonomous communities.

CONCLUSIONS

births in Spain seem to be highly intervened. In this study, a certain equity criterion was found concerning interventionism during childbirth in Spain. Healthcare influenced female intervention, satisfaction, and perception levels for obstetric violence; this evidences that female empowerment plays an important role.

The usual suspect: cross-sectional study of fundal pressure at second stage of delivery and the association with pelvic floor damage

INTRODUCTION AND HYPOTHESIS

Uterine fundal pressure is applied to accelerate birth by increasing the expulsive force of the uterus in the second stage of delivery. The aim of the study was to evaluate the effect of using uterine fundal pressure during the second stage of delivery on the rate of pelvic floor damage among primiparous women using three-dimensional transperineal ultrasonography.

METHODS

The women were divided into two groups: the fundal pressure group included women where the fundal pressure maneuver was applied (n = 39); the control group included women who delivered spontaneously without fundal pressure (n = 47). 3D-TPU was performed within 48 h of delivery, and LAM biometry, LAM defect and loss of tenting were determined.

RESULTS

Anteroposterior hiatal dimensions on resting, maximal Valsalva and maximal PFMC were found to be higher in the fundal pressure group (p < 0.0001, p = 0.008, p = 0.007, respectively). The mean hiatal area at rest was larger in the fundal pressure group than in the control group (p = 0.04). The rate of LAM defect was significantly higher in the fundal pressure group (p = 0.001). The rate of loss of tenting was significantly higher in the fundal pressure group (p < 0.0001). According to multivariate regression models, the fundal pressure was the only independent factor associated with LAM defect (OR = 5.63; 95% CI = 12.01-15.74) and loss of tenting (OR = 8.74; 95% CI = 2.89-26.43).

CONCLUSIONS

Fundal pressure during the second stage of delivery is associated with a higher risk of LAM defect and loss of anterior vaginal wall support.

CLINICAL TRIAL REGISTRATION

NCT03752879.

Evidence-based intrapartum practice and its associated factors at a tertiary teaching hospital in the Philippines, a descriptive mixed-methods study

Background

Evidenced-based practice is a key component of quality care. However, studies in the Philippines have identified gaps between evidence and actual maternity practices. This study aims to describe the practice of evidence-based intrapartum care and its associated factors, as well as exploring the perceptions of healthcare providers in a tertiary hospital in the Philippines.

Methods

A mixed-methods study was conducted, which consisted of direct observation of intrapartum practices during the second and third stages, as well as semi-structured interviews and focus group discussions with care providers to determine their perceptions and reasoning behind decisions to perform episiotomy or fundal pressure. Univariate and multivariate logistic regression were used to analyse the relationship between observed practices and maternal, neonatal, and environmental factors. Qualitative data were parsed and categorised to identify themes related to the decision-making process.

Results

A total of 170 deliveries were included. Recommended care, such as prophylactic use of oxytocin and controlled cord traction in the third stage, were applied in almost all the cases. However, harmful practices were also observed, such as intramuscular or intravenous oxytocin use in the second stage (14%) and lack of foetal heart rate monitoring (57%). Of primiparae, 92% received episiotomy and 31% of all deliveries received fundal pressure. Factors associated with the implementation of episiotomy included primipara (adjusted Odds Ratio [aOR] 62.3), duration of the second stage of more than 30 min (aOR 4.6), and assisted vaginal delivery (aOR 15.0). Factors associated with fundal pressure were primipara (aOR 3.0), augmentation with oxytocin (aOR 3.3), and assisted delivery (aOR 4.8). Healthcare providers believe that these practices can prevent laceration. The rate of obstetric anal sphincter injuries (OASIS) was 17%. Associated with OASIS were assisted delivery (aOR 6.0), baby weights of more than 3.5 kg (aOR 7.8), episiotomy (aOR 26.4), and fundal pressure (aOR 6.2).

Conclusions

Our study found that potentially harmful practices are still conducted that contribute to the occurrence of OASIS. The perception of these practices is divergent with current evidence, and empirical knowledge has more influence. To improve practices the scientific evidence and its underlying basis should be understood among providers.

Attention to childbirth and delivery in a university hospital: comparison of practices developed after Network Stork

OBJECTIVE

to compare, after four years of the implementation of the Stork Network, the obstetric practices developed in a university hospital according to the classification of the World Health Organization.

METHOD

cross-sectional study carried out in the year of adherence to the Stork Network (377 women) and replicated four years later (586 women). Data were obtained through medical records and a structured questionnaire. The Chi-square test was used in the analysis.

RESULTS

four years after the implementation of the Stork Network, in Category A practices (demonstrably useful practices/good practices), there was increased frequency of companions, non-pharmacological methods, skin-to-skin contact and breastfeeding stimulation, and decreased freedom of position/movement. In Category B (harmful practices), there was reduction of trichotomy and increased venoclysis. In Category C (practices with no sufficient evidence), there was increase of Kristeller's maneuver. In Category D (improperly used practices), the percentage of digital examinations above the recommended level increased, as well as of analgesics and analgesia, and there was decrease of episiotomy.

CONCLUSION

these findings indicate the maintenance of a technocratic and interventionist assistance and address the need for changes in the obstetric care model. A globally consolidated path is the incorporation of midwife nurses into childbirth for the appropriate use of technologies and the reduction of unnecessary interventions.

Disrespect and abuse of women during childbirth in public health facilities in Arba Minch town, south Ethiopia - a cross-sectional study

Introduction

Disrespect and abuse of women during childbirth is one of the deterring factors to skilled childbirth utilization, especially in low and middle-income countries.

Objective

The objective of this study was to assess the prevalence of women’s disrespect and abuse during childbirth in public health facilities in Arba Minch town, south Ethiopia.

Methods

Institution-based cross-sectional study design was employed at all public health institutions in Arba Minch town, south Ethiopia. A systematic random sampling method was used to include 281 women who had given birth at public health institutions between January 01 and February 28, 2017. Data were collected through face to face interview by four data collectors and they were supervised by the principal investigator during the entire period of data collection. A semi-structured pretested questionnaire was used to collect the data. Epi info version 7.1.2.0 and SPSS version 24 were used to enter and analyze the data, respectively.

Results

The overall prevalence of non-respectful care was 98.9%. The women’s right to information and informed consent was the most frequently violated right with a prevalence of 92.5% (95% CI: 90.9, 94.1) followed by non-dignified care (36.7, 95% CI: 34.9, 38.5), physical abuse (29.5%, 95% CI: 24.2, 34.8), discrimination (18.1%, 95% CI: 13.6, 22.6), non-confidential care (17.1%, 95% CI: 12.7, 21.5) and abandonment of care (4.3%, 95% CI: 3.1, 5.5). Rural residence, giving birth in the hospital, having no or low educational status and giving birth by cesarean route were factors significantly associated with specific women’s rights violations.

Conclusions and recommendations

The prevalence of women’s disrespect and abuse during childbirth at the health care facilities in this study area is very high. Therefore, health managers need to work hard to tackle the problem.

Respectful and disrespectful care in the Czech Republic: an online survey

BACKGROUND

Respectful maternity care includes treating women with dignity, consulting them about preferences, gaining consent for treatment, respecting their wishes, and giving care based on evidence, not routines. In the absence of any documented evidence, this study aimed to ascertain maternity care-givers' perceptions of respectful care provided for childbearing women in Czech Republic.

METHODS

Following ethical approval, an online quantitative survey with qualitative comments was completed by 52 respondents recruited from workshops on promoting normal birth, followed by snowball sampling. The majority were midwives (50%) or doulas (46%) working in one of 51 hospitals, or with homebirths. Chi-square analysis was used for comparisons.

RESULTS

Non-evidenced-based interventions, described as 'always' or 'frequently' used in hospitals, included application of electronic fetal monitoring in normal labour (n = 40, 91%), shaving the perineum (n = 10, 29%), and closed-glottal pushing (n = 32, 94%). Positions stated as most often used for spontaneous vaginal births were semi-recumbent (n = 31, 65%) or lying flat (n = 15, 31%) in hospital, and upright at home (n = 27, 100%). Average episiotomy and induction of labour rates were estimated at 40 and 26%, respectively, higher than accepted norms. Eighteen respondents (46%) said reasons for performing vaginal examinations were not explained to women in hospitals, and 21 (51%) said consent was 'never' sought. At home, 25 (89%) said reasons were explained, and permission 'always' sought (n = 22, 81%). Thirteen (32%) said hospital clinicians explained why artificial rupture of membranes was necessary, but only ten (25%) said they 'always' sought permission. The majority said that hospital clinicians 'never'/'almost never' explained reasons for performing an episiotomy (13 = 34%), gained permission (n = 20, 54%) or gave local anaesthetic (n = 19, 51%). Contrastingly, 17 (100%) said midwives at home explained the reasons for episiotomy and asked permission. When clinicians disagreed with women's decisions, 13 (35%) respondents said women might be told to 'face the consequences', six (16%) stated that the 'psychological pressure' experienced caused women to 'give up and give their permission', and four (11%) said the intervention would be performed 'against her will.'

CONCLUSIONS

Findings reveal considerable levels of disrespectful, non-evidenced-based, non-consensual and abusive practices that may leave women with life-long trauma.

Does gentle assisted pushing or giving birth in the upright position reduce the duration of the second stage of labour? A three-arm, open-label, randomised controlled trial in South Africa

Introduction

Gentle assisted pushing (GAP) is an innovative method of applying gentle, steady pressure to a woman’s uterine fundus during second stage of labour. This randomised trial evaluated GAP in an upright position, compared with upright position alone or routine practice (recumbent posture).

Methods

An open-label, hospital-based, randomised trial was conducted in Eastern Cape, South Africa. Randomisation occurred following at least 15 min in second stage of labour. Participants were randomly assigned (1:1:1) using computer-generated block randomisation of variable size using opaque, sealed, numbered envelopes. Primary analysis was intention to treat. Participants were healthy, nulliparous, consenting women with a singleton pregnancy in cephalic presentation where vaginal birth was anticipated. The primary outcome was mean time from randomisation to birth.

Results

1158 participants were randomly allocated to GAP (n=388), upright position (n=386) and routine practice (n=384), with no loss to follow-up. Baseline characteristics were largely similar. In the experimental arm, GAP was applied a median of two times (IQR 1.0–3.0). Women in upright position alone spent a median of 6 min (IQR 3.0–10.0) upright. Mean duration from randomisation to birth was not different across groups (mean (SD) duration: 24.1 (34.9) min in GAP group, 24.6 (30.5) min in upright group, 25.0 (39.3) min in routine practice group). There were no differences in secondary outcomes, except that at two sites maternal discomfort was greater for both GAP and upright position compared with routine practice; at the other sites there were no differences.

Conclusion

No benefit was identified from GAP in the second stage; some women found the position uncomfortable. The use of fundal pressure should be limited to further research to determine techniques or settings in which it can safely assist vaginal birth. Women should be encouraged to assume the position they find most comfortable.

Trial registration number

PACTR201502001034448.