Analgesia and satisfaction in childbirth (the Queen Charlotte's 1000 Mother Survey)

Maternal Attitude and Knowledge Regarding Painless Labor: A Report from a Referral Hospital in Northern Iran

Background

Pregnant women's knowledge about labor analgesia and the acceptance rate of this method are still undesirable in developing countries.

Objectives

This study aimed to examine pregnant women's knowledge, attitude, and acceptance of painless labor.

Methods

The present observational study was conducted in a referral university hospital in Northern Iran from September 2022 to April 2023. Eligible women were interviewed; the data were analyzed in SPSS v. 22 and expressed in numbers and percentages. A P-value < 0.05 was considered significant.

Results

The data from 369 eligible women with an average age of 30.39 ± 5.42 years were analyzed. Of these women, 7.6% had minimal information about labor analgesia, and 92.4% declared they were almost aware of the procedure. Only 6 women (1.8%) believed that the anesthesiologists were responsible for performing labor analgesia, while 218 (63.9%) considered it the duty of obstetricians-gynecologists. Besides, 294 women (86.2%) requested this method, and 259 (76%) were ready to pay for it. Moreover, 166(48.7%) had no fear of the procedure. Nonpharmacologic methods were the first choice for 164 (48.1%), while Entonox was the last choice for 26 (7.6%). A significant association was observed between maternal level of education and willingness to pay for painless delivery (P = 0.006), knowledge of who performs it (P = 0.015), requesting a painless delivery (P = 0.0001), options related to the preferred method for painless delivery (P = 0.001), and being ready to pay for a painless delivery service (P = 0.0001).

Conclusions

Despite the poor maternal knowledge regarding the process of painless labor, the majority of the women requested the method and were ready to pay for it. These promising findings encourage the application of practical strategies to remove barriers.

Consistency of Delivery Mode Increases Chinese Mothers' Maternal Satisfaction: The Effect of Perception of Support from Medical Staff and Mothers' Self-Efficacy

Maternal satisfaction is essential for women. Extant research has focused on how a practical delivery method effects maternal satisfaction. This article tried to explore the effect of the consistency of delivery mode between mothers' expectations and their experience of maternal satisfaction and proposed the mediating effect of the perception of support from medical staff and the moderated mediation effect of maternal self-efficacy. Based on two studies, this article found that the consistency of the delivery mode has a positive effect on maternal satisfaction, and women's perception of support from medical staff mediated the above relationship. The maternal perception of self-efficacy has a moderated mediation effect; specifically, for women with a high level of self-efficacy, the positive effect of the consistency of the delivery mode on maternal satisfaction through perception support from medical staff is stronger. This article highlights the importance of the consistency of the delivery mode between women's expectations and the experience of maternal satisfaction and the psychological mechanisms involved. The results extend the theoretical research on ethics in childbirth and provide implications for improving women's maternal satisfaction from medical staff and themselves.

The impact of obstetric interventions and complications on women's satisfaction with childbirth a population based cohort study including 16,000 women

Background

As a quality marker and a tool for benchmarking between units, a visual analogue scale (VAS) (ranging from 1 to 10) to estimate woman’s satisfaction with childbirth was introduced in 2014. This study aimed to assess how obstetric interventions and complications affected women’s satisfaction with childbirth.

Methods

A retrospective cohort study including 16,775 women with an available VAS score who gave birth between January 2016 and December 2017. VAS score, maternal and obstetric characteristics were obtained from electronic medical records and crude and adjusted odds ratios (aOR) were calculated.

Results

The total prevalence of dissatisfaction with childbirth (VAS 1–3) was 5.7%. The main risk factors for dissatisfaction with childbirth were emergency cesarean section, aOR 3.98 95% confidence interval (CI) 3.27–4.86, postpartum hemorrhage ≥2000 ml, aOR 1.85 95%CI 1.24–2.76 and Apgar score < 7 at five minutes, aOR 2.95 95%CI 1.95–4.47. The amount of postpartum hemorrhage showed a dose-response relation to dissatisfaction with childbirth. Moreover, labor induction, instrumental vaginal delivery, and obstetric anal sphincter injury were significantly associated with women’s dissatisfaction with childbirth. A total number of 4429/21204 (21%) women giving birth during the study period had missing values on VAS. A comparison of characteristics between women with and without a recorded VAS score was performed. There were statistically significant differences in maternal age and maternal BMI between the study population and excluded women due to missing values on VAS. Moreover, 64% of the women excluded were multiparas, compared to 59% in the study population.

Conclusions

Obstetric interventions and complications, including emergency cesareans section and postpartum hemorrhage, were significantly related to dissatisfaction with childbirth.

Such events are common and awareness of these associations might lead to a more individualized care of women during and after childbirth.

Labor pain in women with and without severe fear of childbirth: A population-based, longitudinal study

BACKGROUND

This prospective study aims to investigate whether severe fear of childbirth increases pain perceptions during birth and whether co-occurring maternal health and birth factors as well as length and weight of the child explain the association.

METHODS

The study sample comprised women with a vaginal delivery and was drawn from the Akershus Birth Cohort. Data from the hospital birth's record and questionnaires at weeks 17-19 and 32 of pregnancy and 8 weeks postpartum were used (n = 1649). Analysis of variance and analysis of covariance were conducted to examine whether ratings of labor pain differed significantly between women with and without severe fear of childbirth and which factors explained the difference.

RESULTS

Women with severe fear of childbirth experienced significantly more labor pain than women without severe fear of childbirth (P < .01). However, when controlling for symptoms of maternal depression and anxiety, use of epidural/spinal anesthetic or nitrous oxide gas, and menstrual pain, this difference was no longer significant (P = .09).

DISCUSSION

Although the results show that labor pain is related to multiple physiological and psychological factors in a complex manner, symptoms of maternal depression and anxiety seem to play a central role for the experience of labor pain, and should therefore be focused on by health practitioners.

Relaxation techniques for pain management in labour

BACKGROUND

Many women would like to avoid pharmacological or invasive methods of pain management in labour and this may contribute to the popularity of complementary methods of pain management. This review examined currently available evidence on the use of relaxation therapies for pain management in labour. This is an update of a review first published in 2011.

OBJECTIVES

To examine the effects of mind-body relaxation techniques for pain management in labour on maternal and neonatal well-being during and after labour.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (9 May 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 5 2017), MEDLINE (1966 to 24 May 2017), CINAHL (1980 to 24 May 2017), the Australian New Zealand Clinical Trials Registry (18 May 2017), ClinicalTrials.gov (18 May 2017), the ISRCTN Register (18 May 2017), the WHO International Clinical Trials Registry Platform (ICTRP) (18 May 2017), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (including quasi randomised and cluster trials) comparing relaxation methods with standard care, no treatment, other non-pharmacological forms of pain management in labour or placebo.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We attempted to contact study authors for additional information. We assessed evidence quality with GRADE methodology.

MAIN RESULTS

This review update includes 19 studies (2519 women), 15 of which (1731 women) contribute data. Interventions examined included relaxation, yoga, music and mindfulness. Approximately half of the studies had a low risk of bias for random sequence generation and attrition bias. The majority of studies had a high risk of bias for performance and detection bias, and unclear risk of bias for, allocation concealment, reporting bias and other bias. We assessed the evidence from these studies as ranging from low to very low quality, and therefore the effects below should be interpreted with caution.RelaxationWe found that relaxation compared to usual care provided lowered the intensity of pain (measured on a scale of 0 to 10 with low scores indicating less pain) during the latent phase of labour (mean difference (MD) -1.25, 95% confidence interval (CI) -1.97 to -0.53, one trial, 40 women). Four trials reported pain intensity in the active phase; there was high heterogeneity between trials and very low-quality evidence suggested that there was no strong evidence that the effects were any different between groups for this outcome (MD -1.08, 95% CI -2.57 to 0.41, four trials, 271 women, random-effects analysis). Very low-quality evidence showed that women receiving relaxation reported greater satisfaction with pain relief during labour (risk ratio (RR) 8.00, 95% CI 1.10 to 58.19, one trial, 40 women), and showed no clear benefit for satisfaction with childbirth experience (assessed using different scales) (standard mean difference (SMD) -0.03, 95% CI -0.37 to 0.31, three trials, 1176 women). For safety outcomes there was very low-quality evidence of no clear reduction in assisted vaginal birth (average RR 0.61, 95% CI 0.20 to 1.84, four trials, 1122 women) or in caesarean section rates (average RR 0.73, 95% CI 0.26 to 2.01, four trials, 1122 women). Sense of control in labour, and breastfeeding were not reported under this comparison.YogaWhen comparing yoga to control interventions there was low-quality evidence that yoga lowered pain intensity (measured on a scale of 0 to 10) with low scores indicating less pain) (MD -6.12, 95% CI -11.77 to -0.47, one trial, 66 women), greater satisfaction with pain relief (MD 7.88, 95% CI 1.51 to 14.25, one trial, 66 women) and greater satisfaction with childbirth experience (MD 6.34, 95% CI 0.26 to 12.42 one trial, 66 women (assessed using the Maternal Comfort Scale with higher score indicating greater comfort). Sense of control in labour, breastfeeding, assisted vaginal birth, and caesarean section were not reported under this comparison.MusicWhen comparing music to control interventions there was evidence of lower pain intensity in the latent phase for women receiving music (measured on a scale of 0 to 10 with low scores indicating less pain) (MD -0.73, 95% CI -1.01 to -0.45, random-effects analysis, two trials, 192 women) and very low-quality evidence of no clear benefit in the active phase (MD -0.51, 95% CI -1.10 to 0.07, three trials, 217 women). Very low-quality evidence suggested no clear benefit in terms of reducing assisted vaginal birth (RR 0.41, 95% CI 0.08 to 2.05, one trial, 156 women) or caesarean section rate (RR 0.78, 95% CI 0.36 to 1.70, two trials, 216 women). Satisfaction with pain relief, sense of control in labour, satisfaction with childbirth experience, and breastfeeding were not reported under this comparison.Audio analgesiaOne trial evaluating audio analgesia versus control only reported one outcome and showed no evidence of benefit in satisfaction with pain relief.MindfulnessOne trial evaluating mindfulness versus usual care found an increase in sense of control for the mindfulness group (using the Childbirth Self-Efficacy Inventory) (MD 31.30, 95% CI 1.61 to 60.99, 26 women). There is no strong evidence that the effects were any different between groups for satisfaction in childbirth, or for caesarean section rate, need for assisted vaginal delivery or need for pharmacological pain relief. No other outcomes were reported in this trial.

AUTHORS' CONCLUSIONS

Relaxation, yoga and music may have a role with reducing pain, and increasing satisfaction with pain relief, although the quality of evidence varies between very low to low. There was insufficient evidence for the role of mindfulness and audio-analgesia. The majority of trials did not report on the safety of the interventions. Further randomised controlled trials of relaxation modalities for pain management in labour are needed. Trials should be adequately powered and include clinically relevant outcomes such as those described in this review.

Massage, reflexology and other manual methods for pain management in labour

BACKGROUND

Many women would like to avoid pharmacological or invasive methods of pain management in labour, and this may contribute towards the popularity of complementary methods of pain management. This review examined the evidence currently available on manual methods, including massage and reflexology, for pain management in labour. This review is an update of the review first published in 2012.

OBJECTIVES

To assess the effect, safety and acceptability of massage, reflexology and other manual methods to manage pain in labour.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register (30 June 2017), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 6), MEDLINE (1966 to 30 June 2017, CINAHL (1980 to 30 June 2017), the Australian New Zealand Clinical Trials Registry (4 August 2017), Chinese Clinical Trial Registry (4 August 2017), ClinicalTrials.gov, (4 August 2017), the National Center for Complementary and Integrative Health (4 August 2017), the WHO International Clinical Trials Registry Platform (ICTRP) (4 August 2017) and reference lists of retrieved trials.

SELECTION CRITERIA

We included randomised controlled trials comparing manual methods with standard care, other non-pharmacological forms of pain management in labour, no treatment or placebo. We searched for trials of the following modalities: massage, warm packs, thermal manual methods, reflexology, chiropractic, osteopathy, musculo-skeletal manipulation, deep tissue massage, neuro-muscular therapy, shiatsu, tuina, trigger point therapy, myotherapy and zero balancing. We excluded trials for pain management relating to hypnosis, aromatherapy, acupuncture and acupressure; these are included in other Cochrane reviews.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality, extracted data and checked data for accuracy. We contacted trial authors for additional information. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included a total of 14 trials; 10 of these (1055 women) contributed data to meta-analysis. Four trials, involving 274 women, met our inclusion criteria but did not contribute data to the review. Over half the trials had a low risk of bias for random sequence generation and attrition bias. The majority of trials had a high risk of performance bias and detection bias, and an unclear risk of reporting bias. We found no trials examining the effectiveness of reflexology.MassageWe found low-quality evidence that massage provided a greater reduction in pain intensity (measured using self-reported pain scales) than usual care during the first stage of labour (standardised mean difference (SMD) -0.81, 95% confidence interval (CI) -1.06 to -0.56, six trials, 362 women). Two trials reported on pain intensity during the second and third stages of labour, and there was evidence of a reduction in pain scores in favour of massage (SMD -0.98, 95% CI -2.23 to 0.26, 124 women; and SMD -1.03, 95% CI -2.17 to 0.11, 122 women). There was very low-quality evidence showing no clear benefit of massage over usual care for the length of labour (in minutes) (mean difference (MD) 20.64, 95% CI -58.24 to 99.52, six trials, 514 women), and pharmacological pain relief (average risk ratio (RR) 0.81, 95% CI 0.37 to 1.74, four trials, 105 women). There was very low-quality evidence showing no clear benefit of massage for assisted vaginal birth (average RR 0.71, 95% CI 0.44 to 1.13, four trials, 368 women) and caesarean section (RR 0.75, 95% CI 0.51 to 1.09, six trials, 514 women). One trial reported less anxiety during the first stage of labour for women receiving massage (MD -16.27, 95% CI -27.03 to -5.51, 60 women). One trial found an increased sense of control from massage (MD 14.05, 95% CI 3.77 to 24.33, 124 women, low-quality evidence). Two trials examining satisfaction with the childbirth experience reported data on different scales; both found more satisfaction with massage, although the evidence was low quality in one study and very low in the other.Warm packsWe found very low-quality evidence for reduced pain (Visual Analogue Scale/VAS) in the first stage of labour (SMD -0.59, 95% CI -1.18 to -0.00, three trials, 191 women), and the second stage of labour (SMD -1.49, 95% CI -2.85 to -0.13, two trials, 128 women). Very low-quality evidence showed reduced length of labour (minutes) in the warm-pack group (MD -66.15, 95% CI -91.83 to -40.47; two trials; 128 women).Thermal manual methodsOne trial evaluated thermal manual methods versus usual care and found very low-quality evidence of reduced pain intensity during the first phase of labour for women receiving thermal methods (MD -1.44, 95% CI -2.24 to -0.65, one trial, 96 women). There was a reduction in the length of labour (minutes) (MD -78.24, 95% CI -118.75 to -37.73, one trial, 96 women, very low-quality evidence). There was no clear difference for assisted vaginal birth (very low-quality evidence). Results were similar for cold packs versus usual care, and intermittent hot and cold packs versus usual care, for pain intensity, length of labour and assisted vaginal birth.Music One trial that compared manual methods with music found very low-quality evidence of reduced pain intensity during labour in the massage group (RR 0.40, 95% CI 0.18 to 0.89, 101 women). There was no evidence of benefit for reduced use of pharmacological pain relief (RR 0.41, 95% CI 0.16 to 1.08, very low-quality evidence).Of the seven outcomes we assessed using GRADE, only pain intensity was reported in all comparisons. Satisfaction with the childbirth experience, sense of control, and caesarean section were rarely reported in any of the comparisons.

AUTHORS' CONCLUSIONS

Massage, warm pack and thermal manual methods may have a role in reducing pain, reducing length of labour and improving women's sense of control and emotional experience of labour, although the quality of evidence varies from low to very low and few trials reported on the key GRADE outcomes. Few trials reported on safety as an outcome. There is a need for further research to address these outcomes and to examine the effectiveness and efficacy of these manual methods for pain management.

Amount, Source, and Quality of Support as Predictors of Women's Birth Evaluations

BACKGROUND

This paper examines the separate effects of the perceived amount, source, and quality of support during labor and delivery on women's positive and negative evaluations of their birth experiences.

METHODS

Data come from the Listening to Mothers I and II (LTM) surveys (n = 2,765). Women's perception of support was regressed separately onto indices of positive and negative words that women associated with their labor and delivery.

RESULTS

The total number of support sources, type of support person, and quality of support all impacted women's birth evaluations across different regression models, controlling for demographics, birth interventions, and other birth characteristics. Support overall had a greater effect on increasing women's positive evaluations, but was not as protective against negative evaluations. Support from medical and birth professionals (doctors, nurses, doulas) had the greatest effect on women's positive evaluations. Good partner support was complexly related: it was associated with less positive evaluations but also appeared to have a protective effect against negative birth evaluations.

DISCUSSION

Support in childbirth is a complex concept with multiple dimensions that matter for women's birth evaluations. Support from nursing staff, doctors, and doulas is important for enabling positive evaluations while support from partners is more complexly related to women's evaluations. Research on support for laboring women should more extensively address the division of labor between different sources of support.

The association between labour variables and primiparous women's experience of childbirth; a prospective cohort study

Background

Studies have suggested several risk factors for a negative birth experience among primiparas. Factors that are mentioned frequently include labour dystocia, operative intervention such as acute caesarean section or vacuum extraction, or the infant being transferred to neonatal care. Another important factor mentioned is lack of support from the midwife.

Methods

A study was made of the deliveries of 446 healthy primiparas in a prospective cohort study performed at Soder Hospital, Stockholm, Sweden. Samples of amniotic fluid were collected at delivery and the levels of amniotic fluid lactate (AFL) were measured to give an indication of the metabolism of the uterine tissue. Obstetrical data were collected from birth records.

Postpartum, all the women included in the study were asked to complete the Wijma Delivery Experience Questionnaire (W-DEQ B) that measures the experience of a woman’s delivery. The main objective of the project was to study well-known as well as new factors associated with negative experience of childbirth among a group of healthy primiparas.

Results

Risk factors for reporting a higher level of negative childbirth experience were shown to be a high level of AFL (AOR 3.1, 95%, CI; 1.1-8.9), a longer latent phase (AOR 1.8, 95%, CI; 1.03-3.1), and a low Apgar score (<7 at 1 min) (AOR 13.3, 95%, CI; 1.6-111.0). Those women who had a negative birth experience wanted the midwife to be present more of the time during labour (p = 0.003).

Conclusions

A high AFL level, as a marker of uterine metabolic status, and a longer latent phase are strongly associated with a negative experience of childbirth. A low 1 minute Apgar score of the newborn seems to have the strongest negative influence on the woman’s experience of childbirth, even when the infant recovers immediately.

Better Birth through Games

Childbirth is a complex and multidimensional experience for the mother, riddled with unforgettable emotions and sensations. In today’s cultural climate in California, a mother’s primary attendant for social support throughout labor is usually her partner. Preparing the partner is an integral step to making sure that the mother is well-supported in her birth. Because the mother’s experience is influenced by the support she receives, and because birth partners need more support than is recognized, the author targets birth partners with a learning intervention. The author investigates video games as a vehicle for knowledge transfer to the birth partner, both as currently available and as a positive learning tool. To address the problem of limited access to childbirth preparation methods, especially for under-served Californians, the author investigated, designed, created, and evaluated two tools: The Prepared Partner and Digital Birth. The Prepared Partner is an online Flash game, and Digital Birth is a free iPhone application that is still undergoing revision and testing. Both games allow the user to practice various supportive actions in the realm of childbirth support for a mother in labor. The author found that players met the learning goals due to The Prepared Partner, and answered positively on the survey questions about their enjoyment of the game.

Maternal expectations and experiences of labor analgesia with nitrous oxide

BACKGROUND

Although there are various methods for painless delivery such as using entonox gas, most of the people are unfamiliar or concerned about it yet.

OBJECTIVES

The purpose of this study was to assess maternal expectations and experience of labor analgesia with nitrous oxide.

PATIENTS AND METHODS

In a clinical trial study, 98 pregnant women in active phase of delivery were studied randomly in two groups (intervention group = 49, control group = 49) after obtaining written consent. Efficacy, experience satisfaction, and also expectation of pregnant women about entonox gas in two groups were compared, likewise in intervention group before and after using entonox gas.

RESULTS

Most of the pregnant women receiving entonox gas had less labor pain (91.8%), and were satisfied with it (98%). The severity of pain in the most of entonox user was moderate level (46.94%), while for the control group it was severe (55.10%) which was significant, 40.82% of the mother in entonox group had a severe pain and 10.20% had a very severe pain, whereas in the control group (55.10%) of the mother had a severe pain and 26.53% of the had very severe pain (P = 0.004). efficacy of labor pain was in moderate level in most cases. 49% of pregnant women receiving gas described their experience as a good and excellent. 80.9% indicated that they will request the mentioned painless method in the future. The amount of suffering from gas side effects was mild in most patients of intervention group (63%). Expectations of the majority of pregnant women in intervention group (before receiving gas) and control group for painless delivery were weak (65.3%, 40.9%). The percentage of positive expectations had increased after receiving entonox gas (P = 0.01). There was a difference between the expectations of intervention group receiving entonox gas and control group (P = 0.001). Positive expectations were more in intervention group than the control group. Most differences of expectations in intervention group before and after receiving the gas were about higher efficacy (P = 0.001), more satisfaction (P = 0.001), fewer complications (P = 0.001), information about gas as painless delivery method (P = 0.02), and also previous experience of intolerable labor pain (P = 0.04).

CONCLUSIONS

This study has shown that using entonox gas caused less labor pain, favorable expectations and experiences and also more maternal satisfaction.

Maternal mental health in the first 3-week postpartum: the impact of caregiver support and the subjective experience of childbirth - a longitudinal path model

OBJECTIVE

Acute stress reactions (ASR) and postpartum depressive symptoms (PDS) are frequent after childbirth. The present study addresses the change and overlap of ASR and PDS from the 1- to 3-week postpartum and examines the interplay of caregiver support and subjective birth experience with regard to the development of ASR/PDS within a longitudinal path model.

METHOD

A total of 219 mothers completed questionnaires about caregiver support and subjective birth experience (Salmon's Item List) at 48-6-h postpartum. ASR and PDS were measured for 1- and 3-week postpartum. The Impact of Event Scale (IES) was used to assess ASR, and the Edinburgh Postnatal Depression Scale (EPDS) was used to assess PDS.

RESULTS

ASR was frequent 1-week postpartum (44.7%) and declined till week 3 (24.8%, p <.001), while the prevalence of PDS was continuous (14.2% week 1; 12.6% week 3; p = .380). Favorable reports of caregiver support were related to better subjective childbirth experience, which was related to lower ASR and PDS (controlled for age, mode of delivery, parity, EDA and duration of childbirth).

CONCLUSION

High quality of intrapartum care and positive birth experiences facilitate psychological adjustment in the first 3-week postpartum.

Relaxation techniques for pain management in labour

BACKGROUND

Many women would like to avoid pharmacological or invasive methods of pain management in labour and this may contribute towards the popularity of complementary methods of pain management. This review examined currently available evidence supporting the use of relaxation therapies for pain management in labour.

OBJECTIVES

To examine the effects of relaxation methods for pain management in labour on maternal and perinatal morbidity.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2010), The Cochrane Complementary Medicine Field's Trials Register (November 2011), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 4), MEDLINE (1966 to 30 November 2010), CINAHL (1980 to 30 November 2010), the Australian and New Zealand Clinical Trial Registry (30 November 2010), Chinese Clinical Trial Register (30 November 2010), Current Controlled Trials (30 November 2010), ClinicalTrials.gov, (30 November 2010) ISRCTN Register (30 November 2010), National Centre for Complementary and Alternative Medicine (NCCAM) (30 November 2010) and the WHO International Clinical Trials Registry Platform (30 November 2010).

SELECTION CRITERIA

Randomised controlled trials comparing relaxation methods with standard care, no treatment, other non-pharmacological forms of pain management in labour or placebo.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion and extracted data. Data were checked for accuracy. Two review authors independently assessed trial quality. We attempted to contact study authors for additional information.

MAIN RESULTS

We included 11 studies (1374 women) in the review. Relaxation was associated with a reduction in pain intensity during the latent phase (mean difference (MD) -1.25, 95% confidence interval (CI) -1.97 to -0.53, one trial, 40 women) and active phase of labour (MD -2.48, 95% CI -3.13 to 0.83, two trials, 74 women). There was evidence of improved outcomes from relaxation instruction with increased satisfaction with pain relief (risk ratio (RR) 8.00, 95% CI 1.10 to 58.19, one trial, 40 women) and lower assisted vaginal delivery (RR 0.07, 95% CI 0.01 to 0.50, two trials, 86 women). Yoga was associated with reduced pain (mean difference (MD) -6.12, 95% CI -11.77 to -0.47), one trial, 66 women), increased satisfaction with pain relief (MD 7.88, 95% CI 1.51 to 14.25, one trial, 66 women), satisfaction with the childbirth experience (MD) 6.34, 95% CI 0.26 to 12.42, one trial, 66 women), and reduced length of labour when compared to usual care (MD -139.91, 95% CI -252.50 to -27.32, one trial, 66 women) and when compared with supine position (MD -191.34, 95% CI -243.72 to -138.96, one trial, 83 women). Trials evaluating music and audio analgesia found no difference between groups in the primary outcomes pain intensity, satisfaction with pain relief, and caesarean delivery. The risk of bias was unclear for the majority of trials.

AUTHORS' CONCLUSIONS

Relaxation and yoga may have a role with reducing pain, increasing satisfaction with pain relief and reducing the rate of assisted vaginal delivery. There was insufficient evidence for the role of music and audio-analgesia. However, there is a need for further research.

Maternal goals for childbirth associated with planned vaginal and planned cesarean birth

We describe maternal childbirth goals among women planning either cesarean or vaginal birth. Women in the third trimester planning cesarean or vaginal birth were asked to report up to five childbirth goals. Goal achievement was assessed postpartum. Based on free-text responses, discrete goal categories were identified. Goals and goal achievement were compared between the two groups. Satisfaction was rated on a visual analogue scale and was compared with goal achievement. The sample included 163 women planning vaginal birth and 69 women planning cesarean. Twelve goal categories were identified. Only women planning vaginal birth reported a desire to achieve fulfillment related to childbirth. Women planning cesarean were less likely to express a desire to maintain control over their own responses during childbirth and more likely to report a desire to avoid complications. The 72 women who achieved all stated goals reported significantly higher mean satisfaction scores than the 94 women reporting that at least one goal was not achieved (P  =  0.001). Goal achievement was higher among women planning cesarean than among those planning vaginal birth (52.2% versus 23.1%, P  <  0.001). This research furthers our understanding of women's attitudes regarding cesarean childbirth and definitions of a successful birth experience.

Acupuncture or acupressure for pain management in labour

BACKGROUND

Many women would like to avoid pharmacological or invasive methods of pain management in labour and this may contribute towards the popularity of complementary methods of pain management. This review examined evidence supporting the use of acupuncture and acupressure for pain management in labour.

OBJECTIVES

To examine the effects of acupuncture and acupressure for pain management in labour.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register and The Cochrane Complementary Medicine Field's Trials Register (October 2010), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 4), MEDLINE (1966 to October 2010), and CINAHL (1980 to October 2010).

SELECTION CRITERIA

Published and unpublished randomised controlled trials comparing acupuncture and acupressure with placebo, no treatment or other non-pharmacological forms of pain management in labour. We included all women whether primiparous or multiparous, and in spontaneous or induced labour.

DATA COLLECTION AND ANALYSIS

We performed meta-analysis using risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes. The outcome measures included pain intensity, satisfaction with pain relief, use of pharmacological pain relief, relaxation, caesarean section rate, augmentation with oxytocin, length of labour and anxiety.

MAIN RESULTS

We included 13 trials with data reporting on 1986 women. Nine trials reported on acupuncture and four trials reported on acupressure. Less intense pain was found from acupuncture compared with no intervention (standardised mean difference (SMD) -1.00, 95% confidence interval (CI) -1.33 to -0.67, one trial, 163 women). One trial increased satisfaction with pain relief compared with placebo control (RR 2.38, 95% CI 1.78 to 3.19, 150 women). Reduced use of pharmacological analgesia was found in one trial of acupuncture compared with placebo (RR 0.72, 95% CI 0.58 to 0.88, 136 women), and compared with standard care, however, there was significant heterogeneity (RR 0.68, 95% CI 0.56 to 0.83, three trials, 704 women). Fewer instrumental deliveries from acupuncture were found compared with standard care (RR 0.67, 95% CI 0.46, 0.98, three trials, 704 women); however, there was significant heterogeneity. Pain intensity was reduced in the acupressure group compared with a placebo control (SMD -0.55, 95% CI -0.92 to -0.19, one trial, 120 women), and a combined control (SMD -0.42, 95% CI -0.65 to -0.18, two trials, 322 women). No trial was assessed as being at a low risk of bias for all of the quality domains.

AUTHORS' CONCLUSIONS

Acupuncture and acupressure may have a role with reducing pain, increasing satisfaction with pain management and reduced use of pharmacological management. However, there is a need for further research.

The birth satisfaction scale

PURPOSE

The purpose of this paper is to develop a psychometric scale--the birth satisfaction scale (BSS)--for assessing women's birth perceptions.

DESIGN/METHODOLOGY/APPROACH

Literature review and transcribed research-based perceived birth satisfaction and dissatisfaction expression statements were converted into a scored questionnaire.

FINDINGS

Three overarching themes were identified: service provision (home assessment, birth environment, support, relationships with health care professionals); personal attributes (ability to cope during labour, feeling in control, childbirth preparation, relationship with baby); and stress experienced during labour (distress, obstetric injuries, receiving sufficient medical care, obstetric intervention, pain, long labour and baby's health).

RESEARCH LIMITATIONS/IMPLICATIONS

Women construct their birth experience differently. Views are directed by personal beliefs, reactions, emotions and reflections, which alter in relation to mood, humour, disposition, frame of mind and company kept. Nevertheless, healthcare professionals can use BSS to assess women's birth satisfaction and dissatisfaction. Scores measure their service quality experiences.

SOCIAL IMPLICATIONS

Scores provide a global measure of care that women perceived they received during labour.

ORIGINALITY/VALUE

Finding out more about what causes birth satisfaction and dissatisfaction helps maternity care professionals improve intra-natal care standards and allocate resources effectively. An attempt has been made to capture birth satisfaction's generalised meaning and incorporate it into an evidence-based measuring tool.

Mothers' satisfaction with planned vaginal and planned cesarean birth

We sought to describe maternal satisfaction with childbirth among women planning either cesarean or vaginal birth. We enrolled primiparous women planning cesarean birth and a comparison group planning vaginal birth. After delivery, the maternal subjective experience was assessed with a visual analogue satisfaction scale and the Salmon questionnaire, with scale scores for these aspects of the maternal experience of birth: fulfillment, distress, and difficulty. The sample included 160 women planning vaginal birth and 44 women planning cesarean. Eight weeks postpartum, women planning cesarean reported higher satisfaction ratings ( P = 0.023), higher scores for fulfillment ( P = 0.017), lower scores for distress ( P = 0.010), and lower scores for difficulty ( P < 0.001). The least favorable scores were associated with unplanned cesarean ( N = 48). Women planning cesarean reported a more favorable birth experience than women planning vaginal birth, due in part to low satisfaction associated with unplanned cesarean. Maternal satisfaction with childbirth may be improved by efforts to reduce unplanned cesarean, but also by support for maternal-choice cesarean.

Phase 1 development of an index to measure the quality of neuraxial labour analgesia: exploring the perspectives of childbearing women

PURPOSE

Modern neuraxial labour analgesia reflects a shift in obstetrical anesthesia thinking - away from a simple focus on pain relief towards a focus on the overall quality of analgesia. However, advances in the methods used to measure outcomes have not kept pace with clinical progress, and these approaches must evolve to facilitate meaningful assessment of the advances provided towards the quality of analgesia. Developing a tool to measure the quality of neuraxial labour analgesia that research has achieved is best guided by women's perspectives. As the initial step in developing an instrument to quantitatively measure quality neuraxial labour analgesia, this qualitative descriptive study explored childbearing women's experiences and perspectives regarding this subject.

METHODS

Twenty-eight postpartum women, all delivering with neuraxial labour analgesia, were recruited from three hospitals in the greater Toronto area. Twenty-five women described a priori plans to use neuraxial labour analgesia, or they described themselves as having been open to the idea. Women's experiences and perspectives of neuraxial labour analgesia were explored in focus groups and in-depth interviews < or =72 hr following childbirth.

RESULTS

Four major themes emerged: 1)The Enormity of Labour Pain; 2) Fear and Anxiety Related to Epidural Pain Relief; 3) What Women Value about Epidural Pain Relief; and 4) The Relative Value of Achieving Epidural Pain Relief vs Avoidance of Epidural Drug Side Effects. Participants broadly described quality neuraxial labour analgesia as pain relief without side effects. Responses affirmed the importance of traditionally measured outcomes as attributes of quality neuraxial labour analgesia, e.g., pain relief and side effects, as well as the overall importance of pain control during labour and delivery. For research to capture the experience of quality neuraxial labour analgesia, findings suggest that this outcome involves physical, cognitive, and emotional dimensions that must be measured. The findings further suggest an important relationship between each of these dimensions and perceptions of control.

CONCLUSIONS

Women's perspectives must be incorporated into the assessment of quality neuraxial labour analgesia in order for research to measure this outcome in a meaningful manner. Study findings have important implications for scale development, interpretation of existing research, and antenatal education.

The Pain of Labour

Labour is an emotional experience and involves both physiological and psychological mechanisms.The pain of labour is severe but despite this its memory diminishes with time.Labour pain has two components: visceral pain which occurs during the early first stage and the second stage of childbirth, and somatic pain which occurs during the late first stage and the second stage.The pain of labour in the first stage is mediated by T10 to L1 spinal segments, whereas that in the second stage is carried by T12 to L1, and S2 to S4 spinal segments.Pain relief in labour is complex and often challenging without regional analgesia.Effective management of labour pain plays a relatively minor role in a woman's satisfaction with childbirth.

Memory of childbirth in the second year: the long-term effect of a negative birth experience and its modulation by the perceived intranatal relationship with caregivers

OBJECTIVE

To assess the memory of various subdimensions of the birth experience in the second year postpartum, and to identify women in the first weeks postpartum at risk of developing a long-term negative memory. DESIGN, METHOD, OUTCOME MEASURES: New mothers' birth experience (BE) was assessed 48-96 hours postpartum (T1) by means of the SIL-Ger and the BBCI (perception of intranatal relationships); early postnatal adjustment (week 3 pp: T1(bis)) was also assessed. Then, four subgroups of women were defined by means of a cluster-analysis, integrating the T1/T1(bis) variables. To evaluate the memory of the BE, the SIL-Ger was again applied in the second year after childbirth (T2). First, the ratings of the SIL-Ger dimensions of T1 were compared to those at T2 in the whole sample. Then, the four subgroups were compared with respect to their ratings of the birth experience at T2 (correlations, ANOVAs and t-tests).

RESULTS

In general, fulfillment, emotional adaptation, physical discomfort, and anxiety improve spontaneously over the first year postpartum, whereas in negative emotional experience, control, and time-going-slowly no shift over time is observed. However, women with a negative overall birth experience and a low level of perceived intranatal relationship at T1 run a high risk of retaining a negative memory in all of the seven subdimensions of the birth experience.

CONCLUSIONS

Women at risk of developing a negative long-term memory of the BE can be identified at the time of early postpartum, when the overall birth experience and the perceived intranatal relationship are taken into account.

Personality disorder, psychiatric symptoms and experience of childbirth among childbearing women in Sweden

OBJECTIVE

to investigate the importance of having a personality disorder or psychiatric symptoms during pregnancy for women's experience of childbirth.

DESIGN

a prospective study of women consecutively recruited during mid-pregnancy. On study entry, the women completed self-rating scales for personality disorders, global functioning level and psychiatric symptoms. Two weeks after the birth, the women completed a questionnaire about their childbirth experiences. Obstetric and neonatal data were collected from maternity ward records. Multivariate logistic regression was used to estimate the likelihood for negative birth experiences.

SETTING

antenatal clinics in Stockholm, Sweden.

PARTICIPANTS

625 primiparous women.

FINDINGS

40 out of 624 (6.4%) women fulfilled the criteria for personality disorder, and 28 out of 625 (4.5%) women were defined as psychiatric cases. No significant differences were found between women with personality disorders, or defined as psychiatric cases, and women without any mental problems regarding their global experience of birth. Women defined as psychiatric cases were more anxious (z=-2.5, p=0.04) during labour than women without mental problems. The strongest predictors of having had a negative global experience of birth were instrumental vaginal delivery (OR 3.2, 95% CI 2.1-5.1) and epidural analgesia (OR 2.4, 95% CI 1.5-3.9).

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

obstetric factors, such as instrumental delivery, seem to be more important than mental problems during pregnancy for women's global experience of birth. Women with psychiatric symptoms during pregnancy need extra support during labour.

Complementary and alternative therapies for pain management in labour

BACKGROUND

Many women would like to avoid pharmacological or invasive methods of pain management in labour and this may contribute towards the popularity of complementary methods of pain management. This review examined currently available evidence supporting the use of alternative and complementary therapies for pain management in labour.

OBJECTIVES

To examine the effects of complementary and alternative therapies for pain management in labour on maternal and perinatal morbidity.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 1), MEDLINE (1966 to February 2006), EMBASE (1980 to February 2006) and CINAHL (1980 to February 2006).

SELECTION CRITERIA

The inclusion criteria included published and unpublished randomised controlled trials comparing complementary and alternative therapies (but not biofeedback) with placebo, no treatment or pharmacological forms of pain management in labour. All women whether primiparous or multiparous, and in spontaneous or induced labour, in the first and second stage of labour were included.

DATA COLLECTION AND ANALYSIS

Meta-analysis was performed using relative risks for dichotomous outcomes and mean differences for continuous outcomes. The outcome measures were maternal satisfaction, use of pharmacological pain relief and maternal and neonatal adverse outcomes.

MAIN RESULTS

Fourteen trials were included in the review with data reporting on 1537 women using different modalities of pain management; 1448 women were included in the meta-analysis. Three trials involved acupuncture (n = 496), one audio-analgesia (n = 24), two trials acupressure (n = 172), one aromatherapy (n = 22), five trials hypnosis (n = 729), one trial of massage (n = 60), and relaxation (n = 34). The trials of acupuncture showed a decreased need for pain relief (relative risk (RR) 0.70, 95% confidence interval (CI) 0.49 to 1.00, two trials 288 women). Women taught self-hypnosis had decreased requirements for pharmacological analgesia (RR 0.53, 95% CI 0.36 to 0.79, five trials 749 women) including epidural analgesia (RR 0.30, 95% CI 0.22 to 0.40) and were more satisfied with their pain management in labour compared with controls (RR 2.33, 95% CI 1.15 to 4.71, one trial). No differences were seen for women receiving aromatherapy, or audio analgesia.

AUTHORS' CONCLUSIONS

Acupuncture and hypnosis may be beneficial for the management of pain during labour; however, the number of women studied has been small. Few other complementary therapies have been subjected to proper scientific study.

Obstetric pain relief and its association with remembrance of labor pain at two months and one year after birth

The association between obstetric pain relief and long-term memory of pain is poorly researched in spite of the fact that a woman's memory of childbirth may affect her emotional wellbeing and future reproduction. The aim of this study was to investigate the association between epidural analgesia and other forms of pain relief, and memory of pain at two months and one year after birth. A national sample of 2482 Swedish speaking women with vaginal delivery or emergency cesarean section preceded by labor were followed from early pregnancy to one year after birth. Data were collected by three postal questionnaires: in early pregnancy, and two months and one year after the birth. Recollection of intense pain at two months and one year was associated with high rates of pain relief, and this was most obvious regarding epidural analgesia in first-time mothers. When comparing women with the same pain score at two months postpartum who had and who did not have an epidural, the first group seemed to have greater difficulty forgetting pain 10 months later. Possible explanations of these findings are discussed.

Hypnosis Antenatal Training for Childbirth (HATCh): a randomised controlled trial [NCT00282204]

BACKGROUND

Although medical interventions play an important role in preserving lives and maternal comfort they have become increasingly routine in normal childbirth. This may increase the risk of associated complications and a less satisfactory birth experience. Antenatal hypnosis is associated with a reduced need for pharmacological interventions during childbirth. This trial seeks to determine the efficacy or otherwise of antenatal group hypnosis preparation for childbirth in late pregnancy.

METHODS/DESIGN

A single centre, randomised controlled trial using a 3 arm parallel group design in the largest tertiary maternity unit in South Australia. Group 1 participants receive antenatal hypnosis training in preparation for childbirth administered by a qualified hypnotherapist with the use of an audio compact disc on hypnosis for re-enforcement; Group 2 consists of antenatal hypnosis training in preparation for childbirth using an audio compact disc on hypnosis administered by a nurse with no training in hypnotherapy; Group 3 participants continue with their usual preparation for childbirth with no additional intervention. Women > 34 and < 39 weeks gestation, planning a vaginal birth, not in active labour, with a singleton, viable fetus of vertex presentation, are eligible to participate. Allocation concealment is achieved using telephone randomisation. Participants assigned to hypnosis groups commence hypnosis training as near as possible to 37 weeks gestation. Treatment allocations are concealed from treating obstetricians, anaesthetists, midwives and those personnel collecting and analysing data. Our sample size of 135 women/group gives the study 80% power to detect a clinically relevant fall of 20% in the number of women requiring pharmacological analgesia - the primary endpoint. We estimate that approximately 5-10% of women will deliver prior to receiving their allocated intervention. We plan to recruit 150 women/group and perform sequential interim analyses when 150 and 300 participants have been recruited. All participant data will be analysed, by a researcher blinded to treatment allocation, according to the "Intention to treat" principle with comprehensive pre-planned cost- benefit and subgroup analyses.

DISCUSSION

If effective, hypnosis would be a simple, inexpensive way to improve the childbirth experience, reduce complications associated with pharmacological interventions, yield cost savings in maternity care, and this trial will provide evidence to guide clinical practice.

Cuidado e conforto durante o trabalho de parto e parto: na busca pela opinião das mulheres

A obstetrícia moderna considera o parto um evento médico-cirúrgico e adota um modelo de assistência tecnicista. Esperava-se que os avanços tecnológicos auxiliassem o trabalho dos cuidadores, proporcionando condições e tempo para ser e estar junto à parturiente. No entanto, esse avanço tecnológico e científico mostra uma enorme fragilidade no que se refere ao cuidado. Realizou-se uma pesquisa quali-quantitativa, descritiva prospectiva, que avaliou a opinião das mulheres puérperas sobre os métodos utilizados para seu cuidado e conforto durante o trabalho de parto e parto. Este trabalho é um recorte dos dados qualitativos, focando os sentimentos das mulheres puérperas durante esta vivência. Com os resultados, pretende-se contribuir na adaptação dos métodos de cuidado e conforto, proporcionando um trabalho de parto humanizado, reforçando na parturiente a confiança em si mesma e na equipe, facilitando e incentivando o parto normal e o exercício saudável da sexualidade, bem como a prevenção das mortes maternas.

An evaluation of pain and "fitness" during labor and its acceptability to women

BACKGROUND

Labor experiences involve many dimensions that change during labor but are rarely measured contemporaneously and longitudinally. We examined pain and "fitness" aspects of women's labor experience and assessed the acceptability to participants.

METHODS

Thirty nulliparas and 20 multiparas in term labor indicated pain and fitness every 45 minutes in contraction-free intervals on visual analog scales from 0 to 10. Fitness implied both physical and psychological strength. Data were analyzed cross-sectionally and longitudinally, with adjustment for analgesia and time dependency. Women received feedback and evaluated their participation on the first day postpartum.

RESULTS

Measurements of pain and fitness ranged from 2 to 22 per woman (mean +/- SD: 7.4 +/- 4.4). Pain scores showed various patterns, mostly increasing from 1.4 (+/- 1.9) at the first to 6.6 (+/- 3.8) at the last measurement in nulliparas and from 1.3 (+/- 2.1) to 6.2 (+/- 4.0) in multiparas. One half of the women declined steadily in fitness throughout labor, occasionally after a slight increase early on. Multiparas entered labor more fit (5.9 +/- 3.0) than nulliparas (3.9 +/- 2.7), but showed a sharper decline so that the difference leveled out just before birth. Although fitness at any one time did not reflect pain levels, fitness and pain were inversely related, especially in nulliparas (p = 0.003). Analgesia affected pain scores but affected fitness only a little. Women's responses were mainly positive, especially in appreciating the feedback. Nevertheless, 32 percent of women skipped one or more measurements, often toward the end or when too close to a contraction.

CONCLUSIONS

Pain and "fitness" are two distinctly different dimensions of labor experience. Repeated longitudinal measurements of elements of well-being are clearly feasible and acceptable to laboring women. They may be useful to assess how labor events and interventions affect women's well-being.

Experience of pain and analgesia with water and land births

Labor is one of the most painful experiences in a woman's life. Does water birth influence the pain experienced? Data from an ongoing, longitudinal, prospective observational study that spans 9 years and includes questionnaires from 12,040 births were used to evaluate pain perception (visual analogue scale (VAS)) and analgesic use. Three birthing methods were compared: water birth, bed birth and Maia stool birth. Based on the VAS, the data show that the different birthing methods do not influence the intensity of pain throughout the different stages of labor. The only significant difference noted was that bed births are more painful in the early first stage, and less painful at the end of the second stage. This later difference may be due to increased use of epidural anesthesia in women choosing a bed birth. Women who choose bed births are significantly less likely than others to have an analgesic-free birth. For primiparas, there is also a small but significant difference showing that water births are less likely to require analgesics compared to Maia stool births. No such difference is seen in women who have given birth previously. We conclude that women who choose bed births perceive more pain in the early first stage of labor, leading them to be more likely to choose an epidural anesthesia in the late first stage, or to use other types of analgesics. Women who choose water births or Maia stool births are more likely to get through labor without using any analgesics.

Pain and pain relief in labour: parturients' experiences

The experiences of 890 parturients were studied across Finland during one week to determine how they experienced labour pain and how effective they regarded the means to alleviate it. The majority of women (72%) had been afraid of labour and 88% had intended to request some pharmacological pain relief. 84% of primiparous and 72% of multiparous rated their pain severe or unbearable. Epidural analgesia was found to be the most effective method in the first stage of labour, but in the second this superiority was no longer apparent. Unfortunately, it seems to be readily available only during office hours in spite of the fact that the majority of deliveries happen outside of that time.

Motor block during epidural infusions for nulliparous women in labour: a randomized double-blind study of plain bupivacaine and low dose bupivacaine with fentanyl

Sixty nulliparous women received epidural infusions in labour of either 0.125% plain bupivacaine or 0.0625% bupivacaine containing 2.5 mcg/ml fentanyl both starting at 12 ml/h and titrated to maintain a sensory block to T10. Those women who received low dose bupivacaine with fentanyl took significantly longer to reach full cervical dilation (P < 0.05). There was no statistical difference between the groups in the number of additional epidural bolus doses required during the infusions. Of the women receiving low dose bupivacaine with fentanyl, 77% required one or no additional top-up doses compared to 87% in the plain bupivacaine group. There was no reduction in the incidence of perineal pain in the group who received fentanyl. Significantly more women who received 0.125% bupivacaine had motor block after 2 h of the infusion (P < 0.05). The mode of delivery was similar in the two groups as was the satisfaction with epidural analgesia in both the first and second stages of labour and with labour overall. There were no significant differences in Apgar scores, umbilical cord blood pH levels or neurologic and adaptive capacity scores at 2 or 24 h. There was no significant difference in the incidence of symptoms 24 h after delivery.

Mothers’ Views of Their Childbirth Experiences 2 Years Mter Planned Caesarean Versus Planned Vaginal Birth for Breech Presentation at Term, in the International Randomized Term Breech Trial

OBJECTIVE

To compare mothers' views at 2 years postpartum after participation in a randomized trial of planned Caesarean and planned vaginal birth for a singleton fetus in breech presentation at term.

STUDY DESIGN

In selected centres in the Term Breech Trial, mothers completed a structured questionnaire at approximately 2 years postpartum to assess their likes and dislikes about their childbirth experiences and their views about their intrapartum care and care providers.

RESULTS

Of 1159 mothers from 85 centres, 917 (79.1%) completed a follow-up questionnaire at 2 years postpartum. Baseline information was similar for both the planned Caesarean and planned vaginal birth groups. Planned Caesarean was associated with less worry about the baby's health (P < 0.001). While other differences were noted in likes and dislikes about their childbirth experiences, women's evaluations of the quality of intrapartum care, the helpfulness of staff, and their involvement in decision-making did not differ in the planned Caesarean delivery and planned vaginal birth groups.

CONCLUSION

Planned mode of delivery influences aspects of women's evaluations of their childbirth experiences but does not affect evaluations of the quality of intrapartum care, support from care providers, or amount of involvement in decision-making.

Delivery room analgesia: an analysis of maternal satisfaction

On the first post-partum day, 324 mothers completed a questionnaire designed to assess maternal perception of delivery room experience. Antenatal pain expectation, actual pain severity, analgesia received, as well as maternal satisfaction and choice of analgesia for future deliveries were recorded. Forty-five percent of primiparae and 36% of multiparae reported that they anticipated suffering extreme pain during delivery. The incidence of unbearable pain was similar among patients who received no analgesia or intravenous pethidine but significantly (P<0.0001) higher when compared to epidural analgesia. During the first stage of labour, continuous epidural analgesia was associated with severe or unbearable pain in 51% and 58% of primiparae and multiparae, respectively. The incidence of severe or unbearable pain during the second stage of labour was 43% and 46% for primiparae and multiparae, respectively. Patient satisfaction with epidural analgesia did not correlate with subjective pain scores. Among mothers who received continuous epidural analgesia 70% described their experience as good or excellent and 65.8% indicated that they would request similar pain relief in the future. Despite advances in obstetric analgesia, women anticipate and actually experience severe pain during childbirth. However, due to psychological and cultural factors, as well as possible post-partum euphoria, satisfaction with the delivery room experience is high.

Epidural infusion or combined femoral and sciatic nerve blocks as perioperative analgesia for knee arthroplasty †

BACKGROUND

Peripheral neural blockade appears to provide effective analgesia with potentially less morbidity than central neuraxial techniques. We compared the relative benefits of combined femoral (3-in-1) and sciatic nerve block with epidural blockade for postoperative knee arthroplasty analgesia.

METHODS

Sixty patients, ASA I-III, undergoing unilateral knee replacement were prospectively randomized to receive either a lumbar epidural infusion or combined single-shot femoral (3-in-1) and sciatic blocks (combined blocks). All patients received standard general anaesthesia. Visual analogue pain scores and rescue opioid requirements were recorded at four time points postoperatively. Patient satisfaction, morbidity, block insertion time, perioperative blood loss and rehabilitation indices were also assessed.

RESULTS

In both groups, pain on movement was well controlled at discharge from recovery and 6 h postoperatively but increased at 24 and 48 h. Median (95% CI) analogue scale scores were 0 (0-0), 15 (0-30), 55 (38-75) and 54 (30-67) mm for epidural block and 0.5 (0-22), 21.5 (10-28), 40 (20-50) and 34.5 (21-55) mm for combined block. VAS pain scores with the combined blocks were significantly lower at 24 h (P=0.004). Total morphine usage was low in both groups: median epidural group 17 mg (8-32) versus combined blocks 13 mg (7.8-27.5). Patient satisfaction was high in both groups with median (95% CI) scores of 100 (85-100), 83 (70-100) and 82 (57-90) mm for epidural and 90 (73-100), 100 (77-100) and 97 (80-100) mm for combined blocks (not significant). Perioperative blood loss and rehabilitation indices were also similar.

CONCLUSIONS

Combined femoral (3-in-1) and sciatic blocks offer a practical alternative to epidural analgesia for unilateral knee replacements.

Hypnosis for pain relief in labour and childbirth: a systematic review

BACKGROUND

In view of widespread claims of efficacy, we examined the evidence regarding the effects of hypnosis for pain relief during childbirth.

METHODS

Medline, Embase, Pubmed, and the Cochrane library 2004.1 were searched for clinical trials where hypnosis during pregnancy and childbirth was compared with a non-hypnosis intervention, no treatment or placebo. Reference lists from retrieved papers and hypnotherapy texts were also examined. There were no language restrictions. Our primary outcome measures were labour analgesia requirements (no analgesia, opiate, or epidural use), and pain scores in labour. Suitable comparative studies were included for further assessment according to predefined criteria. Meta-analyses were performed of the included randomized controlled trials (RCTs), assessed as being of "good" or "adequate" quality by a predefined score.

RESULTS

Five RCTs and 14 non-randomized comparisons (NRCs) studying 8395 women were identified where hypnosis was used for labour analgesia. Four RCTs including 224 patients examined the primary outcomes of interest. One RCT rated poor on quality assessment. Meta-analyses of the three remaining RCTs showed that, compared with controls, fewer parturients having hypnosis required analgesia, relative risk=0.51 (95% confidence interval 0.28, 0.95). Of the two included NRCs, one showed that women using hypnosis rated their labour pain less severe than controls (P<0.01). The other showed that hypnosis reduced opioid (meperidine) requirements (P<0.001), and increased the incidence of not requiring pharmacological analgesia in labour (P<0.001).

CONCLUSION

The risk/benefit profile of hypnosis demonstrates a need for well-designed trials to confirm the effects of hypnosis in childbirth.

How do obstetric variables influence the dimensions of the birth experience as assessed by Salmon’s item list (SIL-Ger)?

OBJECTIVE

To analyse the effect of obstetric variables on four dimensions of the birth experience.

DESIGN/PARTICIPANTS

The birth experience of 251 German-speaking women was assessed at 48-96 h postpartum by means of Salmon's item list--German-language version (SIL-Ger). METHOD/MAIN OUTCOME MEASURES: Statistical correlations and variances between four dimensions of the birth experience (fulfillment, emotional adaptation, negative emotional experience, physical discomfort) and common obstetric variables were calculated. The explained variance is assessed by a stepwise regression analysis.

RESULTS

In general the variance explained by the investigated obstetric variables per se is low. The mode of delivery affects the dimension of negative emotional experience with a constant qualitative worsening in the order of spontaneous deliveries, instrumental deliveries, elective and unplanned caesarean sections. Epidurals are associated neither with positive nor with negative evaluative feelings. To assess the impact of duration, the subjective latent phase of labour has to be taken into consideration in addition to the duration of labour itself. Not only very long durations of labour, but also very short ones may induce negative evaluative feelings in the immediate postpartum.

CONCLUSIONS

Further research on this question must include the aspect of the parturients' subjective perception of both obstetric procedures and the attending staff. Clinicians should be aware that epidurals and elective caesarean sections do not necessarily enhance positive evaluative feelings in the immediate postpartum.

A negative birth experience: prevalence and risk factors in a national sample

BACKGROUND

A woman's dissatisfaction with the experience of labor and birth may affect her emotional well-being and willingness to have another baby. The aim of this study was to investigate the prevalence and risk factors of a negative birth experience in a national sample.

METHODS

A longitudinal cohort study of 2541 women recruited from all antenatal clinics in Sweden during 3 weeks spread over 1 year was conducted. Data were collected by three questionnaires, which measured women's global experience of labor and birth 1 year after the birth, and obtained information on possible risk factors during pregnancy and 2 months after the birth.

RESULTS

Seven percent of the women had a negative birth experience. The following risk factors were found: (1) factors related to unexpected medical problems, such as emergency operative delivery, induction, augmentation of labor, and infant transfer to neonatal care; (2) factors related to the woman's social life, such as unwanted pregnancy and lack of support from partner; (3) factors related to the woman's feelings during labor, such as pain and lack of control; and (4) factors that may be easier to influence by the caregivers, such as insufficient time allocated to the woman's own questions at antenatal checkups, lack of support during labor, and administration of obstetric analgesia.

CONCLUSIONS

Many risk factors were related to unexpected medical problems and participants' social background. Of the established methods to improve women's birth experience, childbirth education and obstetric analgesia seemed to be less effective, whereas support in labor and listening to the woman's own issues may be underestimated.

Maternal satisfaction with childbirth and intrapartum analgesia in nulliparous labour

OBJECTIVE

To assess maternal satisfaction with childbirth and intrapartum pain relief in nulliparous women labouring at term.

METHODS

Prospective randomised clinical trial comparing epidural and non-epidural analgesic techniques on term labour outcomes in nulliparous women. Within 24 h of delivery the women were surveyed regarding their opinions about the birthing experience and the allocated analgesic regimen. A postal survey was conducted 6 months postpartum to assess opinions about intrapartum analgesia in a subsequent pregnancy.

RESULTS

A total of 992 women were randomised to receive continuous midwifery support (CMS) or epidural (EPI) analgesia on presentation for delivery. There was a high crossover rate from CMS to EPI (61.2%) and a lesser non-compliance rate in the EPI group (27.8%). The early post-partum recollections revealed a high satisfaction with epidural analgesia and lower satisfaction with alternative pain relief measures. Ten percent of women in the CMS group reported negative feelings about their allocated pain relief compared with 1% in the EPI group (P < 0.001), and 10% of all women reported negative feelings about their overall childbirth experience. At the 6-month postpartum survey factors associated with the planned use of epidural analgesia in a subsequent pregnancy were induction of labour (odds ratio (OR) 2.4, 95% confidence interval (CI) 1.2, 4.7) and prior utilisation of epidural analgesia (OR 28.1, 95% CI 14.5, 54.7).

CONCLUSIONS

Maternal satisfaction with intrapartum analgesia was significantly higher with epidural analgesia than non-epidural analgesic techniques. Overall satisfaction scores for labour and delivery were high regardless of analgesic approach, reflecting the multiple issues other than pain relief that are involved in the childbirth experience.

Birth as a multidimensional experience: comparison of the English- and German-language versions of Salmon's Item List

Results concerning satisfaction with the birth experience in different trials are difficult to compare, owing to a lack of internationally used research scales. Salmon's Item List (SIL) is easy-to-handle and would therefore be very helpful for research as well as for obstetric clinic quality control. Two hundred and fifty-one patients were investigated using a German-language version of SIL (SIL-ger); the statistical evaluation was carried out by means of a principal components analysis. Principal components analysis revealed two major findings: (1) as stated by other authors the birth experience is multidimensional, each aspect influencing the others in a non-linear way; (2) in addition to Salmon's dimensions (i.e. postnatal 'fulfillment', intranatal 'physical discomfort' and intranatal 'emotional distress') another postnatal dimension labeled 'negative emotional experience' was detected. Not only are intranatal experiences multidimensional, but so too are evaluative feelings afterwards. In addition to fulfillment, as developed by Salmon, a dimension of negative emotional experience needs to be taken into account. This dimension does not correlate in a linear way with fulfillment. It is appropriate to use SIL in research. Before using it for purposes of clinical quality control, however, larger samples need to be evaluated in order to prove the stability of the factor structure.

A randomised controlled trial of epidural compared with non-epidural analgesia in labour

OBJECTIVES

To investigate possible short and long term side effects of epidural analgesia, compared with non-epidural analgesia for pain relief in labour.

DESIGN

Randomised controlled study, with long term follow up by questionnaire. Analysis by intention-to-treat.

SETTING

Busy maternity unit within a district general hospital in England.

PARTICIPANTS

Three hundred and sixty nine primigravid women in labour were included (randomised allocation: epidural n = 184, non-epidural n = 185).

MAIN OUTCOME MEASURES

Backache at three and twelve months after delivery, instrumental delivery rates and maternal opinion of pain relief in labour.

RESULTS

No significant differences were found in the reported incidence of backache between the groups at three months: middle backache [22% vs 20%, chi2 = 0.057, P = 0.81; odds ratio (95% CI) 1.4(0.9-2.3)]; low backache [35% vs 34%, chi2 = 0.009, P = 0.92; odds ratio (95% CI) 1.0(0.6-1.6)]. Nor were there significant differences at 12 months: [middle backache 16% vs 16%, chi2 = 0.013, P = 0.91; odds ratio (95% CI) 1.0(0.5-1.8)]; or low backache [35% vs 27%, chi2 = 1.91, P = 0.17; odds ratio (95% CI) 1.4(0.9-2.3)]. The incidence of instrumental delivery was somewhat higher in the epidural group [30% vs 19%, odds ratio (95% CI) 1.77(1.09-2.86)]. Maternal satisfaction was not significantly different between the groups.

CONCLUSIONS

This study provided no evidence to support the suggestion of a direct association between the use of epidural anaesthesia in labour and the incidence of long term backache. Despite a significant proportion of women in each group not receiving their allocated analgesia, a significant difference in terms of instrumental delivery rates remained. Satisfaction in both groups of women was high.