Women's perspectives of the stages and phases of labour

Nulliparous women's lived experiences of the prolonged passive stage of labour: A thematic analysis based on descriptive phenomenology

INTRODUCTION

Prolonged progress can occur in the first and second stages of labour and may contribute to a negative birth experience. However, previous studies have mainly focused on quantitative aspects or overall birth experience, and little is known about women's experiences of a prolonged passive second stage.

OBJECTIVE

To describe the lived experiences of a prolonged passive second stage of labour in nulliparous women.

METHODS

A qualitative study was conducted with 15 nulliparous women with a passive second stage lasting three hours or more. Data were analysed using thematic analysis based on descriptive phenomenology.

RESULTS

The analysis resulted in four themes: "An unknown phase" that entailed remaining in a phase that the women lacked an awareness of. "Trust and mistrust in the body's ability" represents the mindset for vaginal birth as well as feelings of powerlessness and self-guilt. The theme "Loss of control" included experiences of frustration, fatigue, and having to deny bodily instincts. "Support through presence and involvement" signifies support through the midwife's presence in the birthing room, although there were also descriptions of emotional or physical absence.

CONCLUSIONS

The findings contribute to the understanding of prolonged labour based on women's lived experiences and add to the body of knowledge about the prolonged passive second stage. This study highlights that women need support through information, presence, and encouragement to remain in control. It can be beneficial during birth preparation to include knowledge about the passive second stage together with unexpected or complicated situations during birth, such as prolonged labour.

Women's experiences and needs concerning care and support during the various phases of childbirth and the postnatal period: Analysis of free-text comments based on Quality from the Patient's Perspective in Sweden

INTRODUCTION

Positive birth experiences can be a decisive factor in the well-being and future health of both women and their newborns. The quality of care is a multidimensional concept influenced by the external structure of the organization, the administrative qualities of the environment, and the individual patient's preferences about care. The aim was to describe women's preferences and experiences concerning support and treatment, and their perception of quality of care during all phases of labor and the postnatal period.

METHODS

Free-text comments of 635 women from four different open comment questions were analyzed. A qualitative content analysis was conducted in two steps: an inductive phase followed by a deductive phase using the Quality of care from a Patient's Perspective framework (QPP).

RESULTS

A total of 1148 free-text comments were coded; and 10 sub-categories were created and inserted under the QPP framework covering the latent meaning of the sub-category. Five of the sub-categories were sorted under the identity-oriented approach, four under physical-technical conditions, and one under the sociocultural atmosphere and reflected the women's experiences and needs regarding support and treatment during early labor, the active phase of labor, and the postnatal period.

CONCLUSIONS

High-quality care and support are important aspects for women during childbirth, irrespective of the phase of labor or postnatal period. The need for individualized care, active participation in one's own birth and using a family centered approach were also emphasized. Organizational factors influenced the quality of care and were particularly noticeable during birth.

The effect of preinduction cervical length measurement with three different ultrasonographic methods on predicting delivery time

AIM

This study aimed to evaluate the effect of preinduction cervical length (CL) measurement by transvaginal (TV), transperineal (TP), and transabdominal (TA) ultrasonography (USG) on the time of delivery and to compare these three sonographic methods in terms of superiority over one another.

METHODS

This study included TV, TP, and TA CL measurements in pregnant women who were planned to undergo induction of labor at 37 weeks' gestation or later. The correlations between the said three methods and BISHOP scores were evaluated. These three methods were compared in terms of superiority in predicting the time of delivery.

RESULTS

Pregnant women at 37-42 weeks' gestation undergoing labor induction were included, and all three methods were used for CL measurements. Three methods were correlated with each other (p < 0.001) and with BISHOP scores (p < 0.001).

CONCLUSION

The correlation between all three methods and BISHOP scores indicates that TP and TA USG can be used instead of TV USG. On the other hand, while TA USG did not give a clear result in the accurate estimation of vaginal delivery time, TP, and TV USG gave both accurate and close results. When all these data are evaluated, it is concluded that TPU can be used safely instead of TVU, especially in patients receiving induction.

A Pharmacotherapeutic Approaches for Managing Labour Pain Using Synthetic Drugs and Natural Therapies

The birth of a child is a critical and potentially traumatic experience for women, entailing multiple physiological and psychosocial changes. The psychological effects of childbirth pain can have both immediate and long-term effects on the mother's health and her bond with her child. Many studies investigated the different ranges of synthetic drugs available for pain control in labour, inclusive of neuraxial analgesics, inhaled analgesics, and various opioids. The inadequate efficacy and unfavourable side effects of these synthetic drugs prevent appropriate pharmacotherapy, resulting in a quest for natural therapies for reducing labour pain. Herbal therapies (aromatherapy) using several essential oils obtained from various natural plants are another alternative that calms and manages the mind and body through aromatic compounds that have neurological and physiological effects. The review discussed the safety profile of various synthetic drugs with their dosage information and also deliberated on the mechanism and safety profile of various natural plants that are used in aromatherapy. The review also briefly highlighted the other non-pharmacological miscellaneous techniques such as TENS, hypnosis, immersion in water, acupuncture, massage, and different other tactics that aim to assist women in coping with pain in labour.

Women's experience of early labour in a free-standing birth centre: Midwifing embodied labour

ISSUE

Women who present at hospital labour wards in early labour must often meet measurable diagnostic criteria before admission.

BACKGROUND

Early labour is a phase of neurohormonal, emotional, and physical changes that are often not measurable. When admission to birthplace is based on results of diagnostic procedures, women's embodied knowledge may be disregarded.

AIM

To describe the early labour experience of women with spontaneous onset of labour in a free-standing birth centre, as well as midwifery care when women arrived in labour.

METHODOLOGY

An ethnographic study was conducted in 2015 in a free-standing birth centre after receiving ethics approval. The findings for this article were drawn from a secondary analysis of the data, which included interview data with women and detailed field notes of midwives' activities related to early labour.

FINDINGS

The women in this study were instrumental in the decision-making process to stay at the birth centre. Observational data showed that vaginal exams were rarely conducted when women arrived at the birth centre and were not a deciding factor in admission.

DISCUSSION

The women and midwives co-constructed early labour based on the lived experience of women and the meaning that this experience held for both.

CONCLUSION

Given the growing concern about the need for respectful maternity care, this study provides examples of good practice in listening to women, as well as an illustration of the consequences of not doing so.

Symptoms of onset of labour and early labour: A scoping review

BACKGROUND

Early labour care often insufficiently addresses the individual needs of pregnant women leading to great dissatisfaction. In-depth knowledge about symptoms of onset of labour and early labour is necessary to develop women-centred interventions.

QUESTION OR AIM

To provide an overview on the current evidence about pregnant women's symptoms of onset of labour and early labour.

METHODS

We conducted a scoping review in the five databases PubMed, Web of Science, CINHAL Complete, PsychInfo and MIDIRS in May 2021 and August 2022 using a sensitive search strategy. A total of 2861 titles and abstracts and 290 full texts were screened independently by two researchers using Covidence. For this article, data was extracted from 91 articles and summarised descriptively and narratively.

FINDINGS

The most frequently mentioned symptoms were 'Contractions, labour pain' (n = 78, 85.7 %), 'Details about the contractions' (n = 51 articles, 56.0 %), 'Positive and negative emotions' (n = 50, 54.9 %) and 'Fear and worries' (n = 48 articles, 52.7 %). Details about the contractions ranged from a slight pulling to unbearable pain and the emotional condition varied from joy to great fear, showing an extraordinary diversity of symptoms highlighting the very individual character of early labour.

DISCUSSION

A comprehensive picture of varying and contradicting symptoms of onset of labour and early labour was drawn. Different experiences indicate different needs. This knowledge builds a good basis to develop women-centred approaches to improve early labour care.

CONCLUSION

Further research is necessary to design individualised early labour interventions and evaluate their effectiveness.

Early labour experience questionnaire: Translation and cultural adaptation into German

PROBLEM

Evidence on early labour care suggests that women's needs are not adequately met.

BACKGROUND

Women's perceptions of early labour management impact on their overall birth experience. Valid measurement tools are needed for evaluation and improvement of early labour care.

AIM

Translation and cultural adaptation of the Early Labour Experience Questionnaire for use in a German context.

METHODS

Translation and adaptation followed internationally recognised guidelines. The process comprised for- and backward translation, an expert panel review using a three-round modified Delphi process and cognitive interviews with representatives of the target group using paraphrasing and retrospective probing. The interviews were conducted online, video-recorded and transcribed. Based on the results of the interviews the pilot version of the questionnaire was compiled.

FINDINGS

Nine experts, including a representative of the target group, participated in the Delphi process. Twelve cognitive interviews were conducted. Most of the translation and adaptation issues needing clarification related to differences in the organisation of maternity care, the term early labour and the translation of the single word expressions for women's affective state in early labour. Few problems emerged during cognitive interviews and related to conceptual understanding, reference points, instructions, and response categories. The pilot version of the German Early Labour Experience Questionnaire (G-ELEQ) comprises a total of 25 items.

CONCLUSION

With the G-ELEQ a tool for measuring women's early labour experience in the German context with good face and content validity is available. Psychometric testing is now needed to assess the instrument's validity and reliability.

Describing the transition from late pregnancy into early labour - A prospective cohort study

OBJECTIVE

The time between self-assessed first symptoms and clinical confirmation of labour onset is marked by uncertainty, particularly for primiparas. Accordingly, primiparas often seek professional care to confirm their perceptions of labour onset. This paper describes the transition into early labour among primiparas considering their level of certainty in labour onset and their perception of labour onset symptoms prior to birth.

METHODS

A prospective exploratory cohort study was conducted in Germany between July 2020 - March 2021 among a convenience sample of 69 primiparas. Respondents recorded in a non-validated questionnaire their perceptions of nine symptoms and degree of certainty about labour onset every day from 37 weeks gestation. Descriptive analysis included certainty in labour onset and dedicated symptoms in relation to days before birth.

RESULTS

The participants (n=69) reported a little certainty of labour onset up to 32 days before birth and most of them became certain up to four days before birth. Associated symptoms were regular and irregular pain, symptoms of vaginal loss and emotional symptoms. Gastrointestinal symptoms and nausea were not indicated by a majority. Uncertainty of labour onset, however, was indicated up until the day of birth.

CONCLUSION

Although interpretation is based on a small sample size, primiparas are able to self-diagnose labour onset and report connected symptoms up to four days before birth. We suggest calling this time between self-diagnosis of labour onset and confirmed labour onset based on clinical parameters the transition into early labour.

Exploring women's experiences, views and understanding of vaginal examinations during intrapartum care: A meta-ethnographic synthesis

OBJECTIVE

To conduct a systematic review exploring women's experiences, views and understanding of any vaginal examinations during intrapartum care, in any care setting and by any healthcare professional. Intrapartum vaginal examination is deemed both an essential assessment tool and routine intervention during labour. It is an intervention that can cause significant distress, embarrassment, and pain for women, as well as reinforce outdated gender roles. In view of its widespread and frequently reported excessive use, it is important to understand women's views on vaginal examination to inform further research and current practice.

DESIGN

A systematic search and meta-ethnography synthesis informed by Noblit and Hare (1988) and the eMERGe guidance (France et al. 2019) was undertaken. Nine electronic databases were searched systematically using predefined search terms in August 2021, and again in March 2023. Studies meeting the following criteria: English language, qualitative and mixed-method studies, published from 2000 onwards, and relevant to the topic, were eligible for quality appraisal and inclusion.

FINDINGS

Six studies met the inclusion criteria. Three from Turkey, one from Palestine, one from Hong Kong and one from New Zealand. One disconfirming study was identified. Following both a reciprocal and refutational synthesis, four 3rd order constructs were formed, titled: Suffering the examination, Challenging the power dynamic, Cervical-centric labour culture embedded in societal expectations, and Context of care. Finally, a line of argument was arrived at, which brought together and summarised the 3rd order constructs.

KEY CONCLUSIONS AND IMPLICATIONS OF PRACTICE

The dominant biomedical discourse of vaginal examination and cervical dilatation as central to the birthing process does not align with midwifery philosophy or women's embodied experience. Women experience examinations as painful and distressing but tolerate them as they view them as necessary and unavoidable. Factors such as context of care setting, environment, privacy, midwifery care, particularly in a continuity of carer model, have considerable positive affect on women's experience of examinations. Further research into women's experiences of vaginal examination in different care models as well as research into less invasive intrapartum assessment tools that promote physiological processes is urgently required.

First stage of labour duration and associated risk of adverse neonatal outcomes

Prior evidence evaluating the benefits and harms of expectant labour duration during active first stage is inconclusive regarding potential consequences for the neonate. Population-based cohort study in Stockholm-Gotland region, Sweden, including 46,040 women (Robson 1), between October 1st, 2008 and June 15th, 2020. Modified Poisson regression was used for the association between active first stage of labour duration and adverse neonatal outcomes. 94.2% experienced a delivery with normal neonatal outcomes. Absolute risk for severe outcomes increased from 1.9 to 3.0%, moderate outcomes increased from 2.8 to 6.2% (> 10.1 h). Compared to the reference, (< 5.1 h; median), the adjusted relative risk (aRR) of severe neonatal outcome significantly increased beyond 10.1 h (> 90th percentile) (aRR 1.53, 95% CI 1.26, 1.87), for moderate neonatal outcome the aRR began to slowly increase beyond 5.1 h (≥ 50 percentile; aRR 1.40, 95% CI 1.24, 1.58). Mediation analysis indicate that most of the association was due to a longer active first stage of labour, 13% (severe neonatal outcomes) and 20% (moderate neonatal outcomes) of the risk was mediated (indirect effect) by longer second stage of labour duration. We report an association between increasing active first stage duration and increased risk of adverse neonatal outcomes. We did not observe a clear labour duration risk threshold.

Self-management, care needs and clinical management of primiparous mothers during early labour - a qualitative content analysis

BACKGROUND

Childbearing women face the problem of managing spontaneous onset of labour without professional support. It is their responsibility to diagnose and react to early labour and subsequently recognise the right time to seek support. Institutional guidelines of clinics aim to admit childbearing women when in established labour. This explains why women in early labour are often advised to stay at home, which can be overwhelming and dissatisfying. This study aims to understand the self- and clinical management of early labour and care needs of first-time mothers during early labour.

METHODS

A qualitative approach was used involving four focus group discussions with a total of N = 18 mothers. Included were primiparous women who had given birth at term within the last 6 months and who experienced spontaneous onset of labour. Elective caesarean section or induction of labour were thereby exclusion criteria. The interviews followed a semi-structured, literature-based guide. Content analysis was applied.

RESULTS

Thirteen codes were summarised within three themes: 'self-management', 'care needs' and 'professional management'. Various coping strategies and measures such as positive thinking or taking a bath helped women in managing early labour at home. The need for reassurance, professional guidance and pain management led them to seek professional support, which was initially accompanied by a feeling of inhibition. This negative emotion was mostly unjustified since many women felt well cared for and taken seriously in their needs.

CONCLUSION

Coping strategies and professional care help women going through early labour. Yet, there still exists insecurity about the justified timing in seeking professional support. An individual assessment of the women's coping resources and their needs is required to promote shared decision making and give high-standard care.

Early labour experience and labour characteristics after introduction of an electronic early labour educational intervention

OBJECTIVE

The study's aim was to compare first-time mothers' experience of early labour and subsequent labour characteristics before and after introducing an online early labour educational intervention. This article also reports on further testing of the underlying structure of the of the Early Labour Experience Questionnaire (ELEQ) in a Norwegian setting.

METHODS

Pre- and post-intervention cohorts were recruited. The ELEQ was translated into Norwegian, back-translated and distributed among primiparous mothers whilst in hospital. Confirmatory factor analyses were used to evaluate model fit, and the internal consistency of the scale was measured by Cronbach's α coefficient. The relationship between cohorts and demographic characteristics were analysed using chi-square statistics and t-tests.

RESULTS

Confirmatory factor analysis of the Swedish version of the ELEQ for primiparous women showed an acceptable fit. Neither the overall score nor the scores on the subscales for emotional well-being, emotional distress and perceptions of midwifery care differed significantly, but there was a significant difference between the groups on a few of the items. The cervix was significantly more dilated upon admission in the post-intervention group, and oxytocin use was significantly reduced. The number of telephone consultations increased significantly after the intervention was introduced.

CONCLUSION

The intervention did not improve women's experience with early labour. However, women who received the intervention were admitted in more advanced labour and required less oxytocin. The increased number of telephone consultations may indicate that an online early labour educational programme cannot replace women's need to communicate directly with staff.

Maternal childbirth experience and time in labor: a population-based cohort study

A negative childbirth experience may have long term negative effects on maternal health. New international guidelines allow a slower progress of labor in the early active phase. However, a longer time in labor may influence the childbirth experience. In this population-based cohort study including 26,429 women, who gave birth from January 2016 to March 2020, the association between duration of different phases of active labor and childbirth experience was studied. The women assessed their childbirth experience by visual analogue scale (VAS) score. Data was obtained from electronic medical records. The prevalence of negative childbirth experience (VAS 1–3) was 4.9%. A significant association between longer duration of all labor phases and a negative childbirth experience was found for primi- and multipara. The adjusted odds ratio (aOR (95%CI)) of negative childbirth experience and longer time in active labor (above the 90th percentile) in primipara was 2.39 (1.98–2.90) and in multipara 2.23 (1.78–2.79). In primi-and multipara with duration of labor ≥ 12 h or ≥ 6 h the aOR (95%CI) of negative childbirth experience were 2.22 (1.91–2.58) and 1.91 (1.59–2.26) respectively. It is of great importance to identify and optimize the clinical care of women with longer time in labor to reduce the risk of negative childbirth experience and associated adverse long-term effects.

Routine vaginal examinations compared to other methods for assessing progress of labour to improve outcomes for women and babies at term

BACKGROUND

Routine vaginal examinations are undertaken at regular time intervals during labour to assess whether labour is progressing as expected. Unusually slow progress can be due to underlying problems, described as labour dystocia, or can be a normal variation of progress. Evidence suggests that if mother and baby are well, length of labour alone should not be used to decide whether labour is progressing normally. Other methods to assess labour progress include intrapartum ultrasound and monitoring external physical and behavioural cues. Vaginal examinations can be distressing for women, and overdiagnosis of dystocia can result in iatrogenic morbidity due to unnecessary intervention. It is important to establish whether routine vaginal examinations are effective, both as an accurate measure of physiological labour progress and to distinguish true labour dystocia, or whether other methods for assessing labour progress are more effective. This Cochrane Review is an update of a review first published in 2013.

OBJECTIVES

To compare the effectiveness, acceptability, and consequences of routine vaginal examinations compared with other methods, or different timings, to assess labour progress at term.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth Trials Register (which includes trials from CENTRAL, MEDLINE, Embase, CINAHL, and conference proceedings) and ClinicalTrials.gov (28 February 2021). We also searched the reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of vaginal examinations compared with other methods of assessing labour progress and studies assessing different timings of vaginal examinations. Quasi-RCTs and cluster-RCTs were eligible for inclusion. We excluded cross-over trials and conference abstracts.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all studies identified by the search for inclusion in the review. Four review authors independently extracted data. Two review authors assessed risk of bias and certainty of the evidence using GRADE.

MAIN RESULTS

We included four studies that randomised a total of 755 women, with data analysed for 744 women and their babies. Interventions used to assess labour progress were routine vaginal examinations, routine ultrasound assessments, routine rectal examinations, routine vaginal examinations at different frequencies, and vaginal examinations as indicated. We were unable to conduct meta-analysis as there was only one study for each comparison.  All studies were at high risk of performance bias due to difficulties with blinding. We assessed two studies as high risk of bias and two as low or unclear risk of bias for other domains. The overall certainty of the evidence assessed using GRADE was low or very low.  Routine vaginal examinations versus routine ultrasound to assess labour progress (one study, 83 women and babies) Study in Turkey involving multiparous women with spontaneous onset of labour. Routine vaginal examinations may result in a slight increase in pain compared to routine ultrasound (mean difference -1.29, 95% confidence interval (CI) -2.10 to -0.48; one study, 83 women, low certainty evidence) (pain measured using a visual analogue scale (VAS) in reverse: zero indicating 'worst pain', 10 indicating no pain). The study did not assess our other primary outcomes: positive birth experience; augmentation of labour; spontaneous vaginal birth; chorioamnionitis; neonatal infection; admission to neonatal intensive care unit (NICU). Routine vaginal examinations versus routine rectal examinations to assess labour progress (one study, 307 women and babies) Study in Ireland involving women in labour at term. We assessed the certainty of the evidence as very low. Compared with routine rectal examinations, routine vaginal examinations may have little or no effect on: augmentation of labour (risk ratio (RR) 1.03, 95% CI 0.63 to 1.68; one study, 307 women); and spontaneous vaginal birth (RR 0.98, 95% CI 0.90 to 1.06; one study, 307 women). We found insufficient data to fully assess: neonatal infections (RR 0.33, 95% CI 0.01 to 8.07; one study, 307 babies); and admission to NICU (RR 1.32, 95% CI 0.47 to 3.73; one study, 307 babies). The study did not assess our other primary outcomes: positive birth experience; chorioamnionitis; maternal pain. Routine four-hourly vaginal examinations versus routine two-hourly examinations (one study, 150 women and babies) UK study involving primiparous women in labour at term. We assessed the certainty of the evidence as very low. Compared with routine two-hourly vaginal examinations, routine four-hourly vaginal examinations may have little or no effect, with data compatible with both benefit and harm, on: augmentation of labour (RR 0.97, 95% CI 0.60 to 1.57; one study, 109 women); and spontaneous vaginal birth (RR 1.02, 95% CI 0.83 to 1.26; one study, 150 women). The study did not assess our other primary outcomes: positive birth experience; chorioamnionitis; neonatal infection; admission to NICU; maternal pain. Routine vaginal examinations versus vaginal examinations as indicated (one study, 204 women and babies)  Study in Malaysia involving primiparous women being induced at term. We assessed the certainty of the evidence as low. Compared with vaginal examinations as indicated, routine four-hourly vaginal examinations may result in more women having their labour augmented (RR 2.55, 95% CI 1.03 to 6.31; one study, 204 women). There may be little or no effect on: • spontaneous vaginal birth (RR 1.08, 95% CI 0.73 to 1.59; one study, 204 women); • chorioamnionitis (RR 3.06, 95% CI 0.13 to 74.21; one study, 204 women); • neonatal infection (RR 4.08, 95% CI 0.46 to 35.87; one study, 204 babies); • admission to NICU (RR 2.04, 95% CI 0.63 to 6.56; one study, 204 babies). The study did not assess our other primary outcomes of positive birth experience or maternal pain.

AUTHORS' CONCLUSIONS

Based on these findings, we cannot be certain which method is most effective or acceptable for assessing labour progress. Further large-scale RCT trials are required. These should include essential clinical and experiential outcomes. This may be facilitated through the development of a tool to measure positive birth experiences. Data from qualitative studies are also needed to fully assess whether methods to evaluate labour progress meet women's needs for a safe and positive labour and birth, and if not, to develop an approach that does.

Women's experiences of the second stage of labour

BACKGROUND

The second stage of labour is generally considered as an intensive part of labour. Despite this, knowledge about women's experiences of the second stage of labour is scant.

AIM

To explore experiences of the second stage of labour in women with spontaneous vaginal birth.

METHODS

This is a qualitative study where twenty-one women with a spontaneous birth at term, were interviewed four to ten weeks after birth. Data were analysed using qualitative thematic analysis based on descriptive phenomenology. The participating women had experienced a vaginal birth; some for the first time, having previously given birth by caesarean section and some with a previous vaginal birth.

FINDINGS

Three themes emerged: "An experience of upheaval" which represents the women's experiences of intensity, power and pain during the second stage of labour. "The importance of trusting relationships" signifies the meaning of women's relationships during the second stage of labour. "Becoming a mother" which is characterised by feelings of accomplishment and the experience of the final moments of birth.

CONCLUSION

During the second stage of labour women experienced overwhelming sensations which made evident the importance of trusting relationships with those involved in the birth. The women were in a transformative state between pregnancy and motherhood where experiences of being involved and being provided with information and guidance were all considered crucial. Continuous support should be offered to women during the second stage of labour.

Development of and Experiences With an Informational Website on Early Labor: Qualitative User Involvement Study

Background

The period of regular contractions before 4 cm of cervical dilatation is often referred to as the latent phase or early labor. Women find it challenging to prepare for and cope with this phase of labor, and easily accessed web-based information from reliable sources may be useful in this preparation.

Objective

The aim of this study is to describe the development of a Norwegian website, Latens.no, for people seeking information on early labor and to explore users’ experiences with the website to increase its user-friendliness.

Methods

We developed a website using an iterative process involving a multidisciplinary research team, health personnel, users, a graphic designer, and an expert in software development. We explored the website’s user-friendliness using semistructured individual interviews and the think-aloud method. All interviews were audio recorded and transcribed. We then analyzed the participants’ feedback on the website.

Results

Participants included women who had recently given birth to their first baby (n=2), women who were pregnant with their first baby (n=4), and their partners (n=2). Results from participants’ experiences completing tasks included positive feedback related to the content of Latens.no, positive feedback related to the website’s design, and suggestions for improvement. Participants wanted to find information on early labor on the internet. Moreover, they found the information on the website relevant, trustworthy, and easy to read, and the design was attractive and easy to use. Overall, the participants performed the tasks easily, with few clicks and minimal effort.

Conclusions

The think-aloud method, while performing tasks, allowed for detailed feedback. The participants confirmed the user-friendliness of the website but at the same time provided information enabling improvement. We expect that changes made based on this user-centered design study will further increase the usability and acceptability of Latens.no.

What women emphasise as important aspects of care in childbirth - an online survey

OBJECTIVE

To explore and describe what women who have given birth in Norway emphasise as important aspects of care during childbirth.

DESIGN

The study is based on data from the Babies Born Better online survey, version 2.

SETTING

The maternity care system in Norway.

STUDY POPULATION

Women who gave birth in Norway between 2013 and 2018.

METHOD

Descriptive statistics were used to describe sample characteristics and to compare data from the B3 survey with national data from the Medical Birth Registry of Norway. The open-ended questions were analysed with an inductive thematic analysis.

MAIN OUTCOME MEASURES

Themes developed from two open-ended questions.

RESULTS

The final sample included 8401 women. There were no obvious differences between the sample population and the national population with respect to maternal age, marital status, parity, mode of birth and place of birth, except for the proportion of planned home births. Four themes and one overarching theme were identified; Compassionate and Respectful Care, A Family Focus, Sense of Continuity and Consistency, and Sense of Security. Overarching theme: Coherence in Childbearing.

CONCLUSIONS

Norwegian women across all birth settings emphasise maternity care that authentically focuses on both socio-cultural and psychological aspects of care, and physical and clinical factors. If the positive aspects of care identified in this study are adopted at all levels of the maternity care system and from all care providers, there is a high chance that most women will have a safe outcome, and a strong sense of coherence related to a positive birth and motherhood experience.

TWEETABLE ABSTRACT

Having a baby is a pivotal life changing experience and not just a clinical event, according to a survey of 8400 women in Norway. Positive birth and motherhood experiences depend on maternity staff who are both skilled and kind.

Exploring women's experiences of participation in shared decision-making during childbirth: a qualitative study at a reference hospital in Spain

BACKGROUND

Women's engagement in healthcare decision-making during childbirth has been increasingly emphasised as a priority in maternity care, since it increases satisfaction with the childbirth experience and provides health benefits for women and newborns. The birth plan was developed as a tool to facilitate communication between health professionals and women in Spain, but their value in routine practice has been questioned. Besides, little is known about women's experiences of participation in decision-making in the Spanish context. Thus, this study aimed to explore women's experiences of participation in shared decision-making during hospital childbirth.

METHODS

An exploratory qualitative study using focus groups was carried out in one maternity unit of a large reference hospital in Barcelona, Spain. Participants were first-time mothers aged 18 years or older who had had a live birth at the same hospital in the previous 12 months. Data collected were transcribed verbatim and analysed using a six-phase inductive thematic analysis process.

RESULTS

Twenty-three women participated in three focus groups. Three major themes emerged from the data: "Women's low participation in shared decision-making", "Lack of information provision for shared decision-making", and "Suggestions to improve women's participation in shared decision-making". The women who were willing to take an active role in decision-making encountered barriers to achieving this and some women did not feel prepared to do so. The birth plan was experienced as a deficient method to promote women's participation, as health professionals did not use them. Participants described the information given as insufficient and not offered at a timely or useful point where it could aid their decision-making. Potential improvements identified that could promote women's participation were having a mutually respectful relationship with their providers, the support of partners and other members of the family and receiving continuity of a coordinated and personalised perinatal care.

CONCLUSION

Enhancing women's involvement in shared decision-making requires the acquisition of skills by health professionals and women. The development and implementation of interventions that encompass a training programme for health professionals and women, accompanied by an effective tool to promote women's participation in shared decision-making during childbirth, is highly recommended.

Undisturbed Physiological Birth: Insights from Women Who Freebirth in the United Kingdom

OBJECTIVE

To understand women's experiences of undisturbed physiological birth by exploring the narratives of women who have freebirthed their babies in the United Kingdom (intentionally giving birth without midwives or doctors present).

DESIGN

Unstructured narrative face-to-face interviews were carried out and data were analysed using the Voice Centred Relational Method (VCRM).

PARTICIPANTS

Sixteen women who had freebirthed their babies.

FINDINGS

Women discussed a range of phenomena including birth positions, the fetus ejection reflex, pain, altered states of consciousness, physiological third stages and postnatal experiences that were physically and emotionally positive.

KEY CONCLUSIONS

There is a paucity of literature on physiological birth and limited opportunity for practitioners to witness it. Further research is required on phenomena related to physiological birth so as to better understand how to promote it within the maternity setting and when intervention is justified.

IMPLICATIONS FOR PRACTICE

Standard maternity settings and practice may not be conducive to or reflective of physiological birth. Better understanding of physiological birth is required so that pregnant women and people can be appropriately supported during labour and birth.

Non-pharmacological interventions of pain management used during labour; an exploratory descriptive qualitative study of puerperal women in Adidome Government Hospital of the Volta Region, Ghana

Background

Women have experienced labour pain over the years as various attempts have been made to effectively manage this pain. There is paucity of literature on the experiences and perceptions about labour pain management with the contemporary Ghanaian health system. This study explored the perspective of puerperal women on the use of non-pharmacological labour pain management at Adidome Government Hospital.

Methods

The study adopted an exploratory descriptive qualitative approach as data was collected through individual interviews. Informed consent was obtained from all participants who were purposely sampled until data saturation was reached on the 17th participant. Interviews were audio recorded and transcribed immediately. Thematic analysis was engaged in three interrelated stages, namely data reduction, data display, and data conclusion to analyse the transcript and field notes. Results were presented with supporting quotes from the transcripts.

Results

The women described labour pain as very severe, severe and moderate as the pain lasted more than 12 h. The various strategies adopted in managing labour pains included shouting and walking around, crying and screaming and staying calm and snapping the fingers. Other pain management strategies adopted during labour included women engaged in deep breathing exercises, chatting with other people and relatives, diversion therapy, reassurance, taking a shower, assuming side lying positions, and receiving intravenous therapy. The presence of the husband of a labouring woman during labour improved pain bearing ability.

Conclusion

It is important that midwives institute pragmatic protocols in the labour ward that ensure a relaxing atmosphere for women in labour, respond to the sensitivity and specificity of labouring women needs and when possible significant others (e.g., husband) of the labouring women could be allowed to visit. Labour wards should be made sound proof to allow women the ability to express themselves satisfactorily during labour without fear of being heard outside.

During childbirth, women have complained of severe pains as health personnel over the years keep looking for appropriate means to alleviate the pain. We therefore studied women with children less than 42 days to understand their perspective on the use of non-drug methods in relieving pain during birth. With the intention of exploring this phenomenon we had an interview with 17 women in the Adidome government hospital. The women showed that labour is a very painful experience. The methods they adopted in reducing pain included shouting, walking around the hospital, crying or screaming, staying calm and snapping the fingers. These women were generally happy with the care that was rendered by midwives. Other methods used to reduce pain were taking deep breaths, talking with a family member or friend, taking a bath, assuming a lying position and receiving intravenous infusion. Women who had their husband present during labour said it helped their pain endurance. We therefore suggested that midwives should be encouraging and supportive of women who are in labour and if possible, allow their spouses into the birth room to augment the pain adaptation ability. Also, labour wards should have sound resilient so that women can make any sound if they so wish to.

A qualitative study of Norwegian first-time mothers' information needs in pre-admission early labour

OBJECTIVE

To explore women's experience with information, and their information needs in pre-admission early labour.

DESIGN

A qualitative study with an exploratory and descriptive approach.

SETTING

Five focus group interviews with women attending post-natal care at five different well-baby clinics in South-Eastern Norway in 2019.

PARTICIPANTS

Sixteen first-time mothers who had given birth to a baby 3-17 weeks prior to the focus group interview. All had experience of staying at home in early labour.

FINDINGS

Three themes emerged from the analysis. The first and most substantial theme involved information. The women considered it necessary to have easy access to a suitable amount of trustworthy information at the appropriate time. The second theme described that the women were surprised at how early labour manifested, despite having prepared for it. The third theme was about receiving acknowledgement and support, revealing that information did not meet all woman's needs.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The women found it challenging to prepare for early labour, and no matter how prepared they felt beforehand, unexpected situations arose. Easily accessed online information from reliable sources was useful in early labour, but in order for women to feel safe at home, this should be complemented by telephone conversations with skilled and welcoming midwives in the labour ward. More knowledge about women's information needs in early labour is required, including studies exploring how the information should be provided to help women feel safe when staying at home in early labour.

Women's unmet needs in early labour: Qualitative analysis of free-text survey responses in the M@NGO trial of caseload midwifery

OBJECTIVE

to analyse women's experiences of early labour care in caseload midwifery in Australia.

DESIGN

this study sits within a multi-site randomised controlled trial of caseload midwifery versus standard care. Participant surveys were conducted at 6-weeks and 6-months after birth. Free-text responses about experiences of care were subject to critical thematic analysis in NVivo 11 software.

SETTING

two urban Australian hospitals in different states.

PARTICIPANTS

women 18 years and over, with a singleton pregnancy, less than 24 weeks' pregnant, not planning a caesarean section or already booked with a care provider; were eligible to participate in the trial.

INTERVENTIONS

participants were randomised to caseload midwifery or standard care for antenatal, labour and birth and postpartum care.

MEASUREMENTS AND FINDINGS

The 6-week survey response rate was 58% (n = 1,019). The survey included five open questions about women's experiences of pregnancy, labour and birth, and postnatal care. Nine-hundred and one respondents (88%) provided free text comments which were coded to generate 10 categories. The category of early labour contained data from 84 individual participants (caseload care n = 44; standard care n = 40). Descriptive themes were: (1) needing permission; (2) doing the 'wrong' thing; and (3) being dismissed. Analytic themes were: (1) Seeking: women wanting to be "close to those who know what's going on"; and (2) Shielding: midwives defending resources and normal birth.

KEY CONCLUSIONS

Regardless of model of care, early labour care was primarily described in negative terms. This could be attributed to reporting bias, because women who were neutral about early labour care may not comment. Nevertheless, the findings demonstrate a gap in knowledge about early labour care in caseload midwifery models.

IMPLICATIONS FOR PRACTICE

Maternity services that offer caseload midwifery are ideally placed to evaluate how early labour home visiting impacts women's experiences of early labour.

Antenatal cervical length measurement as a predictor of successful vaginal birth

Background

Antenatal cervical length measurement has paramount importance in the prediction of labor. It was compared to the Bishop Score and incorporated in the modified Bishop score due to its relevance and convenience. It is a more accurate tool that imposes no harm or distress to the patients. The study aimed to evaluate the role of antenatal cervical length measurement in the prediction of a successful vaginal birth and its relation to the duration of labor.

Methods

This was a prospective cohort study, conducted at the emergency ward of obstetrics and gynecology department. We recruited 162 women over 1 year from January 2018 to January 2019. Women eligible for the study had a transvaginal ultrasound for the examination of the cervical length before the onset of labor. The success of vaginal delivery was evaluated.

Results

The mean cervical length (mm) was 43.3 ± 8.0. The majority of the patients labored spontaneously [102 (63.0%)] while the remaining ones required induction of labor due to different causes. One hundred and eight patients (66.7%) had a successful vaginal delivery. The cervical length was significantly shorter among patients who delivered vaginally than those delivered by CS (P-value < 0.001). Multiple factors had a significant role in the prediction of the mode of delivery (cervical length, BMI, the onset of labor, parity). Maternal body mass index and labor induction were associated with a prolonged duration of the active phase of labor.

Conclusion

Antenatal cervical length measurement predicted the mode of delivery as well as the gestational age at which delivery ensued. It can be used in patients’ counseling regarding the mode of delivery.

'The calm before the storm': A qualitative study of fathers' experiences of early labour

BACKGROUND

Early labour care presents a challenge for maternity services and is a cause of dissatisfaction for women planning birth in an obstetric or midwifery unit who may feel unsupported or unwelcome at their planned place of birth. Little is known about the perspectives of men who support their partner during early labour.

METHODS

Opportunity sample offathers (n=12) in the UK who had been present during their partner's labour in the previous twelve months. Semi-structured interviews were audio-recorded and transcribed before thematic analysis.

RESULTS

Fathers learned about the stages of labour during antenatal education and felt well prepared for early labour but found their knowledge difficult to apply, and relied on their partners to decide when to travel to the planned place of birth. Early labour was described as the 'calm before the storm' during which they carried out practical tasks or rested to ensure they could fulfil their role when labour progressed. However, men frequently felt 'like a spare part' during the later stages of labour.

DISCUSSION

The study has implications for antenatal educators, midwives and others supporting couples during pregnancy and labour. It supports reconsideration of how information about labour progress can be most usefully conveyed to couples. Professionals could acknowledge the value of supportive tasks carried out by fathers that might otherwise be experienced as doing 'nothing'. Further research should recruit more diverse samples of men and same-sex couples. Dyadic data collection methods may be of value.

Experiences of women regarding vaginal examination during labor: A qualitative study

The authors' aim in this study was to examine the experiences of women regarding vaginal examination (VE) performed during labor. This qualitative study is based on a hermeneutic-phenomenological approach. Fourteen women within the first 24 hours of the postpartum period following vaginal birth were enrolled in the study. We created six themes under the categories of "past experiences" and "future expectations". It was revealed that women had many negative feelings during the VE such as pain, ache, embarrassment, and fear. We recommend that the health care providers should inform women about relaxation methods that will reduce pain and discomfort.

Birthing the placenta: women's decisions and experiences

BACKGROUND

Previous research examining the birth of the placenta has focussed on quantitative outcomes comparing active and expectant (physiological) management. However, it is also important to understand women's experiences of birthing the placenta.

METHODS

The participant group consisted of 11 women who had expectant management, eight who had active management and one who was unsure. Participants were interviewed in-depth and the data analysed using thematic analysis.

RESULTS

Seven themes were identified in the data relating to before, during and after the birth of the placenta. Before birth themes focused on making decisions and included 'doing the research' and 'natural birth'. During the birth of the placenta themes were 'boundaries of time', 'focusing on baby' and 'sensations'. After the birth themes consisted of 'looking' and 'keeping'.

CONCLUSION

Most of the women considered a physiological birth of the placenta to be an intrinsic element of natural birth. Active management was considered to be an intervention used if complications occurred. In contrast, women who chose active management did not consider the placenta to be an important element of natural birth, and chose active management in order to prevent complications. Decisions about birthing the placenta were informed by Internet sources and previous personal experiences rather than care providers. During the birth of the placenta care providers managed the boundaries of time whilst women focused on their baby. The sensations women described were consistent across both types of management. Women valued seeing their placenta and having the opportunity to keep it, and placenta encapsulation was popular. The findings of this study contribute the experiences of women to the body of knowledge informing practice during the birth of the placenta.

The ontology of early labour (and the difficulties of talking about it): Using interview methods to investigate uncertain and gendered concepts

This article presents reflections on the process of collecting interview data about fathers’ experiences of ‘early labour’. Early labour is the first phase of labour, defined in textbooks by regular contractions and cervical dilation of up to 4 cm. Women are typically encouraged to stay at home during early labour and only travel to hospital when they are in ‘active labour’. Maternity services (and other providers of antenatal education) devote a great deal of attention to educating parents-to-be about the phases of labour and about how to recognise the ‘right time’ to travel to hospital but ‘early’ admission remains a problem. Prompted by suggestions in the existing literature that male partners may influence when women seek admission, my research set out to explore fathers’ understanding and experiences of early labour. However, interviewing fathers about early labour was challenging and, in this article, I will argue that this was due to a particular configuration of practical, epistemological and ontological issues. I argue that early labour is a slippery and uncertain concept beyond the clinical context and that Mol’s ‘multiple ontologies’ provides productive tools for reflecting on the difficulty of asking about early labour, keeping early labour in focus during the interviews, and finding early labour in the data. However, the gendered nature of reproductive social research requires additional analysis to understand the gender dynamics at work when asking about reproductive research objects of multiple or uncertain ontologies.

Women's psychological experiences of physiological childbirth: a meta-synthesis

OBJECTIVE

To synthesise qualitative studies on women's psychological experiences of physiological childbirth.

DESIGN

Meta-synthesis.

METHODS

Studies exploring women's psychological experiences of physiological birth using qualitative methods were eligible. The research group searched the following databases: MEDLINE, CINAHL, PsycINFO, PsycARTICLES, SocINDEX and Psychology and Behavioural Sciences Collection. We contacted the key authors searched reference lists of the collected articles. Quality assessment was done independently using the Critical Appraisal Skills Programme (CASP) checklist. Studies were synthesised using techniques of meta-ethnography.

RESULTS

Eight studies involving 94 women were included. Three third order interpretations were identified: 'maintaining self-confidence in early labour', 'withdrawing within as labour intensifies' and 'the uniqueness of the birth experience'. Using the first, second and third order interpretations, a line of argument developed that demonstrated 'the empowering journey of giving birth' encompassing the various emotions, thoughts and behaviours that women experience during birth.

CONCLUSION

Giving birth physiologically is an intense and transformative psychological experience that generates a sense of empowerment. The benefits of this process can be maximised through physical, emotional and social support for women, enhancing their belief in their ability to birth and not disturbing physiology unless it is necessary. Healthcare professionals need to take cognisance of the empowering effects of the psychological experience of physiological childbirth. Further research to validate the results from this study is necessary.

PROSPERO REGISTRATION NUMBER

CRD42016037072.

Early labour experience questionnaire: Psychometric testing and women's experiences in a Swedish setting

OBJECTIVE

(a) to psychometrically test the Early Labour Experience Questionnaire (ELEQ) among both primi- and multiparous women giving birth in a Swedish setting, and (b) to describe and compare their experiences during early labour in relation to background characteristics.

DESIGN

a cross-sectional study.

SETTING

a county in Sweden.

PARTICIPANTS

primi- and multiparous women with a spontaneous onset of labour after gestational week 37 + 0. In total, n = 1193 women were invited, and n = 754 responded the questionnaire, with a final total of n = 344 primi and n = 410 multiparous women.

METHODS

the ELEQ was translated with cross-cultural adaptation. The validity was determined using exploratory factor analysis with principal axis factoring analyses. Reliability was estimated from the internal consistency using Cronbach's alpha. The relationship between the questionnaire and the demographic characteristics of the participating women were analysed using ANOVA and t-test.

FINDINGS

an explorative factor analysis showed a three-factor solution for primiparas women (SWE-ELEQ-PP) consist of 23 items and a stable factor structure that explained 49.2% of the total variance with sufficient reliability coefficients (0.81-0.86). A four-factor solution for multiparous women (SWE-ELEQ-MP) consist of 22 items, with 52.62% of the total variance explained and with adequate internal consistency reliability coefficients (0.77-0.86) for three factors and relatively low stability (0.62) for the fourth factor with two items. Primiparous women scored significantly higher on items about feeling confused, and significantly lower on some items measuring emotional wellbeing and perceptions of midwifery care compared to multiparous women. Primiparous women with longer early labour (>18 h), scored significantly lower on the perceptions of midwifery care. Primi- and multiparous women who were dissatisfied with their telephone conversation or with not being admitted during early labour, scored significantly lower on emotional wellbeing, higher regarding emotional distress, and significantly lower about perceptions of midwifery care.

KEY CONCLUSIONS

the SWE-ELEQ-PP and SWE-ELEQ-MP are considered valid questionnaires for use in a Swedish setting. Differences exist between parity and the factor structure and experiences in early labour vary. Women less content with early labour management decisions rated perceived midwifery care lower regardless of parity.

IMPLICATION FOR PRACTICE

the questionnaire can be used to evaluate early labour care in a Swedish setting. The result suggests that differences according to parity exist and should be addressed when managing early labour care and a more individualised approach requires considerations.

Duration of spontaneous labour in 'low-risk' women with 'normal' perinatal outcomes: A systematic review

BACKGROUND

Despite decades of research, the concept of normality in labour in terms of its progression and duration is not universal or standardized. However, in clinical practice, it is important to define the boundaries that distinguish what is normal from what is abnormal to enable women and care providers have a shared understanding of what to expect and when labour interventions are justified.

OBJECTIVES

To synthesise available evidence on the duration of latent and active first stage and the second stage of spontaneous labour in women at low risk of complications with 'normal' perinatal outcomes.

SEARCH STRATEGY

PubMed, EMBASE, CINAHL, POPLINE, Global Health Library, and reference lists of eligible studies.

SELECTION CRITERIA

Observational studies and other study designs.

DATA COLLECTION AND ANALYSIS

Four authors extracted data on: maternal characteristics; labour interventions; duration of latent first stage, active first stage, and second stage of labour; and the definitions of onset of latent and active first stage, and second stage where reported. Heterogeneity in the included studies precluded meta-analysis and data were presented descriptively.

MAIN RESULTS

Thirty-seven studies reporting the duration of first and/or second stages of labour for 208,000 women met our inclusion criteria. Among nulliparous women, the median duration of active first stage (when the starting reference point was 4 cm) ranged from 3.7-5.9 h (95th percentiles: 14.5-16.7 h). With active phase starting from 5 cm, the median duration was from 3.8-4.3 h (95th percentiles: 11.3-12.7 h). The median duration of second stage ranged from 14 to 66 min (95th percentiles: 65-138 min) and from 6 to 12 min (95th percentiles: 58-76 min) in nulliparous and parous women, respectively. Sensitivity analyses excluding first and second stage interventions did not significantly impact on these findings CONCLUSIONS: The duration of spontaneous labour in women with good perinatal outcomes varies from one woman to another. Some women may experience labour for longer than previously thought, and still achieve a vaginal birth without adverse perinatal outcomes. Our findings question the rigid limits currently applied in clinical practice for the assessment of prolonged first or second stage that warrant obstetric intervention.

Experiences of early labour management from perspectives of women, labour companions and health professionals: A systematic review of qualitative evidence

OBJECTIVES

to examine evidence of women's, labour companions' and health professionals' experiences of management of early labour to consider how this could be enhanced to better reflect women's needs.

DESIGN

a systematic review of qualitative evidence.

SETTING AND PARTICIPANTS

women in early labour with term, low risk singleton pregnancies, not booked for a planned caesarean birth or post-dates induction of labour, their labour companions, and health professionals responsible for early labour care (e.g. midwives, nurse-midwives, obstetricians, family doctors). Studies from high and middle income country settings were considered.

FINDINGS

21 publications were included from the UK, Ireland, Scandinavia, USA, Italy and New Zealand. Key findings included the impact of communication with health professionals (most usually midwives) on women's decision making; women wanting to be listened to by sympathetic midwives who could reassure that symptoms and signs of early labour were 'normal' and offer clear advice on what to do. Antenatal preparation which included realistic information on what to expect when labour commenced was important and appreciated by women and labour companions. Views of the optimal place for women to remain and allow early labour to progress differed and the perceived benefit of support and help offered by labour companions varied. Some were supportive and helped women to relax, while others were anxious and encouraged women to seek early admission to the planned place of birth. Web-based sources of information are increasingly used by women, with mixed views of the value of information accessed.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

women, labour companions and health professionals find early labour difficult to manage well, with women unsure of how decisions about admission to their planned place of birth are taken. It is unclear why women are effectively left to manage this aspect of their labour with minimal guidance or support. Tailoring management to meet individual needs, with provision of effective communication could reassure women and facilitate timely admission from perspectives of women, their companions, midwives and other health professionals. Information on labour onset and progress, and approaches to pain management, should be shared with women's labour companions to enable them to feel more confident to better support women. Further research is needed of the impact of different models of care and increasing use of web-based information on women's approaches to self-management when labour commences. PROSPERO 2014 CRD 42014009745.

Labour pain experiences and perceptions: a qualitative study among post-partum women in Ghana

Background

Women have experienced severe labour pain over the years and various attempts have been made to effectively manage labour pain. However, there is paucity of literature on the labour pain experience and perceptions about labour pain with the contemporary Ghanaian health system. Therefore this study sought to gain an in-depth understanding on labour pain experiences and perceptions of post-partum women.

Methods

The study adopted an exploratory descriptive qualitative approach and collected data through individual interviews. Informed consent was obtained from all the participants who were purposively sampled. After transcription of interviews, the data were analyzed inductively using content analysis techniques.

Results

Women in this study experienced pain during labour rated as mild, moderate and severe and the pain was felt at the waist area, vagina, lower abdomen and the general body. The women expressed labour pain through crying, screaming and shouting. They prayed to God to help reduce the severe pain. Some women endured the pain, cried inwardly and others showed no sign of pain. Some women believed that crying during labour is a sign of weakness. Pain reliefs such as pethidine (Meperidine) was occasionally given. Non-pharmacologic measures employed included walking around, deep breathing, side-lying, waist holding, squatting, taking a shower and chewing gum. The individuality of pain experience and expression was emphasized and the socio-cultural orientation of women made some of them stoic.

Conclusion

We concluded that it is necessary for all health professionals to manage labour pain effectively taking the socio-cultural context into consideration.

Women's descriptions of childbirth trauma relating to care provider actions and interactions

Background

Many women experience psychological trauma during birth. A traumatic birth can impact on postnatal mental health and family relationships. It is important to understand how interpersonal factors influence women’s experience of trauma in order to inform the development of care that promotes optimal psychosocial outcomes.

Methods

As part of a large mixed methods study, 748 women completed an online survey and answered the question ‘describe the birth trauma experience, and what you found traumatising’. Data relating to care provider actions and interactions were analysed using a six-phase inductive thematic analysis process.

Results

Four themes were identified in the data: ‘prioritising the care provider’s agenda’; ‘disregarding embodied knowledge’; ‘lies and threats’; and ‘violation’. Women felt that care providers prioritised their own agendas over the needs of the woman. This could result in unnecessary intervention as care providers attempted to alter the birth process to meet their own preferences. In some cases, women became learning resources for hospital staff to observe or practice on. Women’s own embodied knowledge about labour progress and fetal wellbeing was disregarded in favour of care provider’s clinical assessments. Care providers used lies and threats to coerce women into complying with procedures. In particular, these lies and threats related to the wellbeing of the baby. Women also described actions that were abusive and violent. For some women these actions triggered memories of sexual assault.

Conclusion

Care provider actions and interactions can influence women’s experience of trauma during birth. It is necessary to address interpersonal birth trauma on both a macro and micro level. Maternity service development and provision needs to be underpinned by a paradigm and framework that prioritises both the physical and emotional needs of women. Care providers require training and support to minimise interpersonal birth trauma.

The Psychological Experience of Physiological Childbirth: A Protocol for a Systematic Review of Qualitative Studies

PURPOSE: The purpose of this systematic review of the literature is to look at the current evidence of the psychological experience of physiological childbirth.

BACKGROUND: Childbirth is a dynamic process in which the fetal and maternal physiology interacts with the woman’s psychosocial context, yet this process is predominantly evaluated using objective, physical measures. Simultaneously, childbirth is also a profound psychological experience with a deep impact in women that is physical, psychological, and social. The description of the psychological processes and experiences that happen during physiological childbirth will likely improve the care women receive during childbirth as health care professionals and carers will have a greater understanding of the process.

METHODS/DESIGN: The electronic databases MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, PsycARTICLES, SocINDEX, and Psychology and Behavioral Sciences Collection will be searched using the EBSCOhost platform to identify studies that meet the inclusion criteria. No language or publication date constraints will be applied. Articles that pass the 3-stage screening process will then be assessed for risk of bias and have their reference lists hand searched.

DISCUSSION: By synthesizing the results of the studies, this systematic review will help illuminate gaps in the literature, direct future research, and inform policymakers.

Being in a safe and thus secure place, the core of early labour: A secondary analysis in a Swedish context

BACKGROUND

Early labour is the very first phase of the labour process and is considered to be a period of time when no professional attendance is needed. However there is a high frequency of women who seek care at the delivery wards during this phase. When a woman is admitted to the delivery ward, one role for midwives is to determine whether the woman is in established labour or not. If the woman is assessed as being in early labour she will probably then be advised to return home. This recommendation is made due to past research that found that the longer a woman is in hospital the higher the risk for complications for her and her child. Women have described how this situation leaves them in a vulnerable situation where their preferences are not always met and where they are not always included in the decision-making process.

AIM

The aim of this study was to generate a theory based on where a woman chooses to be during the early labour process and to increase our understanding about how experiences can differ from place to place.

METHODS

The method was a secondary analysis with grounded theory. The data used in the analysis was from two qualitative interview studies and 37 transcripts.

CONCLUSION

The findings revealed a substantive theory that women needed to be in a safe and thus secure place during early labour. This theory also describes the interplay between how women ascribed their meaning of childbirth as either a natural live event or a medical one, how this influenced where they wanted to be during early labour, and how that chosen place influenced their experiences of labour and birth.

Cashless childbirth, but at a cost: A grounded theory study on quality of intrapartum care in public health facilities in India

AIM

this study aimed to explore and understand the perceptions and experiences of women regarding quality of care received during childbirth in public health facilities.

DESIGN

qualitative in-depth interviews were conducted and analysed using the Grounded Theory approach.

PARTICIPANTS

thirteen women who had given vaginal birth to a healthy newborn infant.

SETTING

participants were interviewed in their homes in one district of Chhattisgarh, India.

DATA COLLECTION

the interview followed a pre-tested guide comprising one key question: How did the women experience and perceive the care provided during labour and childbirth?

FINDINGS

'cashless childbirth but at a cost: subordination during childbirth' was identified as the core category. Women chose a public health facility due to their socio-economic limitations, and to have a cashless and safe childbirth. Participants expressed a sense of trust in public health facilities, and verbalised that free food and ambulance services provided by the government were appreciated. Care during normal birth was medicalised, and women lacked control over the process of their labour. Often, the women experienced verbal and physical abuse, which led to passive acceptance of all the services provided to avoid confrontation with the providers.

CONCLUSIONS

increasingly higher numbers of women give birth in public health facilities in Chhattisgarh, India, and women who have no alternative place to have a safe and normal birth are the main beneficiaries. The labour rooms are functional, but there is a need for improvement of interpersonal processes, information-sharing, and sensitive treatment of women seeking childbirth services in public health facilities.

Diagnosing onset of labor: a systematic review of definitions in the research literature

BACKGROUND

The diagnosis of labor onset has been described as one of the most important judgments in maternity care. There is compelling evidence that the duration of both latent and active phase labor are clinically important and require consistent approaches to measurement. In order to measure the duration of labor phases systematically, we need standard definitions of their onset. We reviewed the literature to examine definitions of labor onset and the evidentiary basis provided for these definitions.

METHODS

Five electronic databases were searched using predefined search terms. We included English, French and German language studies published between January 1978 and March 2014 defining the onset of latent labor and/or active labor in a population of healthy women with term births. Studies focusing exclusively on induced labor were excluded.

RESULTS

We included 62 studies. Four 'types' of labor onset were defined: latent phase, active phase, first stage and unspecified. Labor onset was most commonly defined through the presence of regular painful contractions (71% of studies) and/or some measure of cervical dilatation (68% of studies). However, there was considerable discrepancy about what constituted onset of labor even within 'type' of labor onset. The majority of studies did not provide evidentiary support for their choice of definition of labor onset.

CONCLUSIONS

There is little consensus regarding definitions of labor onset in the research literature. In order to avoid misdiagnosis of the onset of labor and identify departures from normal labor trajectories, a consistent and measurable definition of labor onset for each phase and stage is essential. In choosing standard definitions, the consequences of their use on rates of maternal and fetal morbidity must also be examined.

[Utilization of tacit knowledge by maternal healthcare providers: a systematic mapping of the literature]

INTRODUCTION

The search for efficient answers to strengthen maternal health care has included various sources of evidence for decision making. In this article, we present a systematic mapping of the scientific literature on the use of tacit knowledge in relation to maternal healthcare.

METHODS

A systematic mapping was conducted of scientific articles published in Spanish and English between 1971 and 2014 following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

RESULTS

Of 793 articles, 30 met the inclusion criteria; 60% were from high-income countries and 66.7% were focused on health professionals. We identified a predominance of qualitative methodologies (62%). Four categories regarding the use of tacit knowledge were generated: proposals to improve the organization of the maternal care system (30%) and to improve the care provided to women during the continuum of pregnancy, childbirth and postpartum (26.7%), determination of health workers' perception and skill levels (26.7%) and the interactions between tacit and explicit knowledge in clinical decision making (16.7%).

CONCLUSIONS

This mapping shows that tacit knowledge is an emerging, innovative and versatile research approach used primarily in high-income countries and that includes interesting possibilities for its use as evidence to improve maternal healthcare, particularly in middle- and low-income countries, where it needs to be strengthened.

Women’s Experience of Birth: Childbirth as a Rite of Passage

BACKGROUND: Within midwifery, there is a move toward reclaiming and promoting physiological birth. Because midwifery is woman-centered in nature, it is essential that the experience of birth is understood from the woman’s perspective. To date, there has been little research focusing exclusively on women’s experience of physiological birth.

AIM: The aim of this study was to explore women’s experiences of physiological birth.

METHOD: A narrative approach was taken, and in-depth face-to-face interviews were used to gather birth stories. The participants were 10 women who had recently experienced a physiological birth. Data were analyzed to identify themes occurring across the narratives.

FINDINGS: The findings are presented within the explanatory framework of childbirth as a rite of passage composing of three phases: separation, liminal, and incorporation. During birth, women separated from the external world and sought to minimize external and internal distractions. In the liminal phase, they entered “their own world” and experienced an altered state of consciousness. After their baby was born, they reintegrated with the external world and incorporated their birth experience into their sense of self.

CONCLUSION: The findings of this study suggest that women’s experiences during physiological birth are multidimensional and not aligned with biomedical descriptions of physically defined stages of labor. Birth was an empowering and transformative experience for the women in the study. The rites of passage framework may assist with developing a discourse about birth that resonates with women’s experiences.

Psychometric properties of the Swedish childbirth self-efficacy inventory (Swe-CBSEI)

BACKGROUND

Previous research has reported that women who are admitted to delivery wards in early labour process before an active stage of labour has started run an increased risk of instrumental deliveries. Therefore, it is essential to focus on factors such as self-efficacy that can enhance a woman's own ability to cope with the first stage of labour. However, there was no Swedish instrument measuring childbirth self-efficacy available. Thus, the aim of the study was to translate the Childbirth Self-efficacy Inventory and to psychometrically test the Swedish version on first- time mothers within the Swedish culture.

METHODS

The method included a forward-backward translation with face and content validity. The psychometric properties were evaluated using a Principal Component Analysis and by using Cronbach's alpha coefficient and inter-item correlations. Descriptive statistics and non-parametric tests were used to describe and compare the scales. All data were collected from January 2011 to June 2012, from 406 pregnant women during the gestational week 35-42.

RESULTS

The Swedish version of the Childbirth Self-Efficacy Inventory indicated good reliability and the Principal Component Analysis showed a three-component structure. The Wilcoxon Signed-Ranks Test indicated that the women could differentiate between the concepts outcome expectancy and self-efficacy expectancy and between the two labour stages, active stage and the second stage of labour.

CONCLUSIONS

The Swedish version of Childbirth Self-efficacy Inventory is a reliable and valid instrument. The inventory can act as a tool to identify those women who need extra support and to evaluate the efforts of improving women's self-efficacy during pregnancy.

The emotional journey of labour-women's perspectives of the experience of labour moving towards birth

BACKGROUND

there has been minimal exploration of women's emotional flow during labour and towards birth. This research aimed to capture woman's remembered experiences of this process.

METHOD

a critical feminist standpoint methodology guided this research which used in depth interviews to explore the perspectives of 18 women who had experienced a spontaneous labour and birth. These women all had continuity of care from a known midwife

FINDINGS

women described labour and birth in terms of their emotions. These emotions flowed from excitement at the beginning, to calm as they waited for the labour to strengthen. This waiting time was variable in length and the women were often able to continue with many aspects of normal life. As the labour intensified women described moving into a 'zone' of timelessness and spacelessness; a time of letting go of control. The external world was shut out. Some women described feeling overwhelmed as the birth approached, others felt intensely tired. During the birth the women returned to a state of alertness. Some described shock or disbelief. They were surprised at how effectively their body had worked and taken them through labour.

CONCLUSION AND IMPLICATION FOR PRACTICE

women described labour as defined by their emotions. The feelings described were linear and consistent and may be an indication of normal labour and birth physiology. These descriptions may be helpful when supporting women during labour and birth.