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Kuah S, Simpson B, Salter A, Matthews G, Louise J, Bednarz J, Chandraharan E, Symonds I, McPhee A, Mol BW, Turnbull D, Wilkinson C. Comparison of effect of CTG + STan with CTG alone on emergency Cesarean section rate: STan Australian Randomized controlled Trial (START). ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:462-470. [PMID: 37289946 PMCID: PMC10946943 DOI: 10.1002/uog.26279] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/11/2023] [Accepted: 05/24/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To investigate whether use of ST analysis of the fetal electrocardiogram (STan) as an adjunct to continuous cardiotocography (CTG) reduces the rate of emergency Cesarean section (EmCS) compared with CTG alone. METHODS This was a randomized controlled trial of patients with a singleton fetus in cephalic presentation at ≥ 36 weeks' gestation, requiring continuous electronic fetal monitoring during labor at a tertiary maternity hospital in Adelaide, Australia, between January 2018 and July 2021. Participants were randomized to undergo CTG + STan or CTG alone. The calculated sample size was 1818 participants. The primary outcome was EmCS. Secondary outcomes included metabolic acidosis, a composite adverse perinatal outcome, and other maternal and neonatal morbidity and safety outcomes. RESULTS The present study enrolled 970 women, of whom 967 were included in the primary analysis. EmCS occurred in 107/482 (22.2%) deliveries in the CTG + STan arm and in 107/485 (22.1%) in the CTG arm (adjusted relative risk, 1.02 (95% CI, 0.81-1.27); P = 0.89). There was no difference in the rate of adverse maternal or neonatal outcomes between arms. CONCLUSIONS The addition of STan as an adjunct to continuous CTG did not reduce the EmCS rate. The smaller-than-anticipated sample size meant that this study was underpowered to detect absolute differences of ≤ 5% and, therefore, this negative finding could be due to a Type-2 error. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- S. Kuah
- Women's and Children's HospitalNorth AdelaideSAAustralia
| | - B. Simpson
- Women's and Children's HospitalNorth AdelaideSAAustralia
- Women's and Children's Health, Adelaide Medical SchoolUniversity of AdelaideNorth AdelaideSAAustralia
| | - A. Salter
- School of Public Health, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSAAustralia
| | - G. Matthews
- Women's and Children's HospitalNorth AdelaideSAAustralia
| | - J. Louise
- Women's and Children's Hospital, Faculty of Health and Medical SciencesUniversity of AdelaideNorth AdelaideSAAustralia
| | - J. Bednarz
- School of Public Health, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSAAustralia
- South Australian Health and Medical Research InstituteSAHMRI Women and KidsNorth AdelaideSAAustralia
| | - E. Chandraharan
- Global Academy of Medical Education and Training LtdLondonUK
| | - I. Symonds
- Adelaide Medical School, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSAAustralia
| | - A. McPhee
- South Australian Health and Medical Research InstituteSAHMRI Women and KidsNorth AdelaideSAAustralia
| | - B. W. Mol
- Department of Obstetrics and GynaecologyMonash UniversityClaytonVICAustralia
- Aberdeen Centre for Women's Health Research, School of Medicine, Medical Sciences and NutritionUniversity of AberdeenAberdeenUK
| | - D. Turnbull
- School of Psychology, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSAAustralia
| | - C. Wilkinson
- Women's and Children's HospitalNorth AdelaideSAAustralia
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Barrowclough J, Kool B, Crowther CA. Pregnant women's views on the acceptability, enablers, and barriers of participation in a randomized controlled trial of maternal posture for fetal malposition in labor. Eur J Midwifery 2022; 6:4. [PMID: 35128346 PMCID: PMC8796820 DOI: 10.18332/ejm/144057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/18/2021] [Accepted: 11/18/2021] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Fetal malposition in labor results in adverse maternal and infant health. Whilst evidence for effective interventions is inconclusive, based on the hypothesis that gravity corrects malposition, the feasibility and design of a randomized controlled trial (RCT) to improve maternal and infant health outcomes should be considered. The aim was to assess pregnant women's views on the acceptability, enablers, and barriers of participation in an RCT of maternal posture for fetal malposition in labor. METHODS A web-based anonymous survey of pregnant women was conducted in Auckland during 2020. Quantitative data were summarized descriptively using a chi-squared test to assess differences in proportions. Maternal characteristics influence on women's responses was assessed using cross-tabulation. A thematic content analysis of free text responses was undertaken. RESULTS Most of the 206 respondents were aged 26-35 years (75%), 29-38 weeks pregnant (71%), of European (40%) or Asian (36%) ethnicity, and similarly nulliparous or multiparous. Most women (76%) knew of fetal malposition in labor; however, only 28% were aware of maternal posture to correct this. Most women (86%) were interested in labor research and although 37% would participate in an RCT, almost half (47%) were unsure and a 15% would not participate. Concerns mostly related to comfort (22%). Nearly half of women (49%) would need to consult their partner regarding participation in an RCT. CONCLUSIONS Enablers for participation in a posture trial in labor include measures to enhance maternal comfort, increasing awareness of malposition and the role of posture, and involving partners in pre-trial counselling and recruitment.
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Affiliation(s)
| | - Bridget Kool
- Section of Epidemiology and Biostatics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Buckley VA, Wu J, De Vries B. Outcomes following acute tocolysis prior to emergency caesarean section. Aust N Z J Obstet Gynaecol 2020; 60:884-889. [PMID: 32378185 DOI: 10.1111/ajo.13170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/04/2020] [Indexed: 11/30/2022]
Abstract
AIM To determine if a policy recommending administration of terbutaline prior to emergency caesarean section improved arterial umbilical cord pH. MATERIALS AND METHODS This was a prospective audit between February 2018 and June 2019 among women who underwent a category one or two caesarean section. Neonatal cord gas results and perinatal outcomes were compared before and after the introduction of a policy recommending subcutaneous terbutaline prior to emergency caesarean section. RESULTS Among 423 women in the pre-policy change cohort and 253 post-policy change, there was no difference in arterial cord pH (median pH = 7.24 before the policy and median pH = 7.24 after the policy was introduced, P = 0.88). There was no statistically significant difference in any perinatal outcome, apart from the median arterial cord lactate which was higher in the post-treatment group (4.2 mmol/L vs 3.9 mmol/L, P = 0.006). Maternal heart rate was higher (median 110 vs 95, P < 0.0001) in the post-treatment group. Breastfeeding was more common in the post-treatment group (99% vs 95%, P = 0.005). There was no difference in estimated blood loss or rate of post-partum haemorrhage. A post hoc analysis according to treatment received, limited to caesarean section when the indication was suspected fetal compromise, demonstrated that among women who received terbutaline the rate of low pH (<7.1) was 3.8% (5/130) when terbutaline was given, compared with 6.6% (18/272) when terbutaline was not given (χ2 1 = 1.3, P = 0.26). CONCLUSION Changing our labour ward policy to recommending terbutaline prior to all category one and category two caesarean sections did not change arterial cord pH.
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Affiliation(s)
- Victoria A Buckley
- Obstetrics and Gynaecology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Joyce Wu
- Obstetrics and Gynaecology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Bradley De Vries
- Obstetrics and Gynaecology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,School of Public Health, University of Sydney, Sydney, New South Wales, Australia
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Widmer M, Bonet M, Betrán AP. Would you like to participate in this trial? The practice of informed consent in intrapartum research in the last 30 years. PLoS One 2020; 15:e0228063. [PMID: 31978100 PMCID: PMC6980544 DOI: 10.1371/journal.pone.0228063] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 01/07/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Informed consent is the cornerstone of the ethical conduct and protection of the rights and wellbeing of participants in clinical research. Therefore, it is important to identify the most appropriate moments for the participants to be informed and to give consent, so that they are able to make a responsible and autonomous decision. However, the optimal timing of consent in clinical research during the intrapartum period remains controversial, and currently, there is no clear guidance. OBJECTIVE We aimed to describe practices of informed consent in intrapartum care clinical research in the last three decades, as reported in uterotonics for postpartum haemorrhage prevention trials. METHODS This is a secondary analysis of the studies included in the Cochrane review entitled "Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis" published in 2018. All the reports included in the Cochrane network meta-analysis were eligible for inclusion in this analysis, except for those reported in languages other than English, French or Spanish. We extracted and synthesized data on the time each of the components of the informed consent process occurred. RESULTS We assessed data from 192 studies, out of 196 studies included in the Cochrane review. The majority of studies (59.9%, 115 studies) reported that women were informed about the study, without specifying the timing. When reported, most studies informed women at admission to the facility for childbirth. Most of the studies reported that consent was sought, but only 59.9% reported the timing, which in most of the cases, was at admission for childbirth. Among these, 32 studies obtained consent in the active phase of labour, 17 in the latent phase and in 10 studies the labour status was unknown. Women were consented antenatally in 6 studies and in 8 studies the consent was obtained indistinctly during antenatal care or at admission. Most of the studies did not specified who was the person who sought the informed consent. CONCLUSION Practices of informed consent in trials on use of uterotonics for prevention of postpartum haemorrhage showed variability and substandard reporting. Informed consent sought at admission for childbirth was the most frequent approach implemented in these trials.
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Affiliation(s)
- Mariana Widmer
- Department of Reproductive Health and Research, World Health Organization, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Geneva, Switzerland
| | - Mercedes Bonet
- Department of Reproductive Health and Research, World Health Organization, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Geneva, Switzerland
| | - Ana Pilar Betrán
- Department of Reproductive Health and Research, World Health Organization, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Geneva, Switzerland
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Ayling L, Henry A, Tracy S, Donkin C, Kasparian NA, Welsh AW. How well do women understand and remember information in labour versus in late pregnancy? A pilot randomised study. J OBSTET GYNAECOL 2019; 39:913-921. [PMID: 31064263 DOI: 10.1080/01443615.2019.1575341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Medical informed consent is the process by which a 'competent', non-coerced individual receives sufficient information including risks of a medical procedure and gives permission for it to occur. The capacity to give an informed consent might be impaired during labour. This study aimed to examine women's abilities to understand and remember during labour. Women were prospectively recruited at 36 weeks of gestation and randomised to undertake questionnaires which assessed their ability to understand and remember information. They were randomised to: (1) information given in labour only, written format (2) information in labour, verbal (3) information at 36 weeks plus labour, written (4) information at 36 weeks plus labour, verbal. Immediate comprehension and retention was assessed at 36 weeks, in labour, and 24-72 hours after birth. Forty-nine women completed the questionnaires regarding understanding and retention of information at 36 weeks, six intrapartum, and five postpartum (90% attrition). Women receiving information at 36 weeks and in labour versus in labour had a higher comprehension of pregnancy-related information, its retention, and total score. Women receiving information in late pregnancy and labour may comprehend and retain it better than women only receiving information during labour. Given small sample size, further research is needed to support these preliminary findings. Impact statement What is already known on this subject? The evidence regarding the capacity of labouring women to give informed consent is largely based on women's self-reported experiences or expert opinions and has mixed findings. Existing guidelines recommend that an informed consent should be given antenatally for both clinical practice and research. Studies show that obtaining an informed consent antenatally is neither feasible nor widely implemented. What do the results of this study add? A novel approach to providing empirical evidence regarding women's capacity to comprehend and retain information during labour. Our study confirms the difficulty with antenatal recruitment for intrapartum research. What are the implications of these findings for clinical practice and/further research? This raises ethical concerns regarding the current intrapartum research in which consent is largely sought at the time of the study. Emphasises the need to explore the question 'Do labouring women have the capacity to consent to research?' in order to ensure that women are protected during labour.
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Affiliation(s)
- Laura Ayling
- School of Women's and Children's Health, UNSW Medicine, The University of New South Wales , Kensington , New South Wales , Australia
| | - Amanda Henry
- School of Women's and Children's Health, UNSW Medicine, The University of New South Wales , Kensington , New South Wales , Australia.,Department of Maternal-Fetal Medicine, Royal Hospital for Women , Randwick , New South Wales , Australia
| | - Sally Tracy
- School of Women's and Children's Health, UNSW Medicine, The University of New South Wales , Kensington , New South Wales , Australia.,Midwifery and Women's Health Research Unit, University of Sydney , Camperdown , New South Wales , Australia
| | - Chris Donkin
- School of Psychology, The University of New South Wales , Kensington , New South Wales , Australia
| | - Nadine A Kasparian
- School of Women's and Children's Health, UNSW Medicine, The University of New South Wales , Kensington , New South Wales , Australia.,Heart Centre for Children, The Sydney Children's Hospitals Network (Westmead and Randwick) , Sydney , New South Wales , Australia
| | - Alec W Welsh
- School of Women's and Children's Health, UNSW Medicine, The University of New South Wales , Kensington , New South Wales , Australia.,Department of Maternal-Fetal Medicine, Royal Hospital for Women , Randwick , New South Wales , Australia
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Carlson NS. Current Resources for Evidence-Based Practice, July/August 2017. J Midwifery Womens Health 2017; 62:488-492. [PMID: 28727283 DOI: 10.1111/jmwh.12641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 05/17/2017] [Indexed: 11/27/2022]
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Current Resources for Evidence-Based Practice, July/August 2017. J Obstet Gynecol Neonatal Nurs 2017; 46:e138-e143. [PMID: 28576658 DOI: 10.1016/j.jogn.2017.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Cook WA. Questionable informed consent of vulnerable pregnant research participants in South India - what a staff reminder poster does not say. Nurs Ethics 2015; 22:264-72. [PMID: 25802291 DOI: 10.1177/0969733015573780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Phipps H, Hyett JA, Graham K, Carseldine WJ, Tooher J, de Vries B. Is there an association between sonographically determined occipito-transverse position in the second stage of labor and operative delivery? Acta Obstet Gynecol Scand 2014; 93:1018-24. [DOI: 10.1111/aogs.12465] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 07/16/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Hala Phipps
- RPA Women and Babies; Royal Prince Alfred Hospital; Sydney New South Wales Australia
- Discipline of Obstetrics, Gynaecology and Neonatology; Faculty of Medicine; University of Sydney; Sydney New South Wales Australia
- Faculty of Nursing; University of Sydney; Sydney New South Wales Australia
| | - Jon A. Hyett
- RPA Women and Babies; Royal Prince Alfred Hospital; Sydney New South Wales Australia
- Discipline of Obstetrics, Gynaecology and Neonatology; Faculty of Medicine; University of Sydney; Sydney New South Wales Australia
| | - Kathy Graham
- RPA Women and Babies; Royal Prince Alfred Hospital; Sydney New South Wales Australia
| | - Wendy J. Carseldine
- RPA Women and Babies; Royal Prince Alfred Hospital; Sydney New South Wales Australia
| | - Jane Tooher
- RPA Women and Babies; Royal Prince Alfred Hospital; Sydney New South Wales Australia
| | - Bradley de Vries
- RPA Women and Babies; Royal Prince Alfred Hospital; Sydney New South Wales Australia
- Discipline of Obstetrics, Gynaecology and Neonatology; Faculty of Medicine; University of Sydney; Sydney New South Wales Australia
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