Decision Making about Hospital Arrival among Low-Risk Nulliparous Women after Spontaneous Labor Onset at Home

The RETHINK Study: Could pain catastrophising explain why some women are more likely to attend hospital during the latent phase of labour

OBJECTIVE

To examine the prevalence of pain catastrophising and identify whether it impacts on the timing of hospital admission when in labour.

METHODS

A longitudinal cohort study. Nulliparous women, experiencing an uncomplicated pregnancy in England, were recruited between 25 and 33 weeks gestation. Participants completed two online questionnaires, (1) on recruitment, including the Pain Catastrophizing Scale (PCS) and the Wijma Delivery Expectancy Questionnaire (WDEQ-A) (2) at three weeks postnatal.

RESULTS

A total of 389 eligible participants entered the study. The percentage of women who were pain catastrophisers (PCS ≥ 20) was 28.1 %, while 7.6 % had a high pain catastrophising score (PCS ≥ 30). There was no association between pain catastrophising and the timing of hospital admission. The percentage of women reporting fear of childbirth (WDEQ-A score of ≥ 85) was 10.6 %. Fear of childbirth was highly associated with PCS scores (p <.001) at both the lower (≥20) and higher (≥30) thresholds.

CONCLUSION

Although not statistically significant, there was a tendency for women who pain catastrophise to present to hospital in the latent phase. The highly significant association between PCS and WDEQ-A scores has implications for the identification of these women and suggests that the PCS can be used as a screening tool to identify those women who have heightened fear around pain and who may also go on to develop clinically relevant fear of childbirth. Further studies are needed to confirm the acceptability of the PCS as a screening tool with women.

Nulliparous Women's Expectations and Experiences of Early Labor

PURPOSE

To describe the expectations of early labor by nulliparous pregnant women in their third trimester and first-time mothers' experiences of early labor after they had given birth.

STUDY DESIGN AND METHODS

A descriptive qualitative approach involving semi-structured, video-call interviews conducted between September 2020 and April 2021. Data were analyzed using content analysis.

RESULTS

Twenty-two women took part in this study. Only 3 of the 10 nulliparous pregnant participants reported pain as an expected symptom of early labor. There were two themes identified from interviews with pregnant participants: Desire to stay at home in early labor and Lack of knowledge and two themes from interviews from postpartum participants: Expectations didn't match experiences and Feelings of anxiety and uncertainty during early labor .

CLINICAL IMPLICATIONS

Nulliparous women lack knowledge of and skills to effectively cope with pain during early labor while at home. There is a need for an innovative labor support program for childbearing women to remain safely at home in early labor.

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

BACKGROUND

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

QUESTION OR AIM

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

METHODS

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

FINDINGS

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

DISCUSSION

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

CONCLUSION

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Outcomes of Childbirth Education for Women With Pregnancy Complications

The purpose of this study was to examine associations between pregnancy outcomes and childbirth education, identifying any outcomes moderated by pregnancy complications. This was a secondary analysis of the Pregnancy Risk Assessment Monitoring System, Phase 8 data for four states. Logistic regression models compared outcomes with childbirth education for three subgroups: women with no pregnancy complications, women with gestational diabetes, and women with gestational hypertension. Women with pregnancy complications do not receive the same benefit from attending childbirth education as women with no pregnancy complications. Women with gestational diabetes who attended childbirth education were more likely to have a cesarean birth. The childbirth education curriculum may need to be altered to provide maximum benefits for women with pregnancy complications.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Timing of hospital admission at first childbirth: A prospective cohort study

BACKGROUND AND AIMS

It is difficult for women in labor to determine when best to present for hospital admission, particularly at first childbirth. While it is often recommended that women labor at home until their contractions have become regular and ≤ 5-minutes apart, little research has investigated the utility of this recommendation. This study investigated the relationship between timing of hospital admission, in terms of whether women's labor contractions had become regular and ≤ 5-minutes apart before admission, and labor progress.

METHODS

This was a cohort study of 1,656 primiparous women aged 18-35 years with singleton pregnancies who began labor spontaneously at home and delivered at 52 hospitals in Pennsylvania, USA. Women who were admitted before their contractions had become regular and ≤ 5-minutes apart (early admits) were compared to those who were admitted after (later admits). Multivariable logistic regression models were used to assess associations between timing of hospital admission and active labor status on admission (cervical dilation 6-10 cm), oxytocin augmentation, epidural analgesia and cesarean birth.

RESULTS

Nearly two-thirds of the participants (65.3%) were later admits. These women had labored for a longer time period before admission (median, interquartile range [IQR] 5 hours (3-12 hours)) than the early admits (median, (IQR) 2 hours (1-8 hours), p < 0.001); were more likely to be in active labor on admission (adjusted OR [aOR] 3.78, 95% CI 2.47-5.81); and were less likely to experience labor augmentation with oxytocin (aOR 0.44, 95% CI 0.35-0.55); epidural analgesia (aOR 0.52, 95% CI 0.38-0.72); and cesarean birth (aOR 0.66, 95% CI 0.50-0.88).

CONCLUSIONS

Among primiparous women, those who labor at home until their contractions have become regular and ≤ 5-minutes apart are more likely to be in active labor on hospital admission and less likely to experience oxytocin augmentation, epidural analgesia and cesarean birth.

Women's Perceptions on the Use of Video Technology in Early Labor: Being Able to See

INTRODUCTION

Delaying admission to the birth setting until active labor has commenced has known benefits. However, women and their partners often struggle to stay home in early labor. Research on telephone triage during early labor at home has illuminated significant disadvantages with this model of care, contributing to women feeling dissatisfied with the early birth experience. Research conducted with midwives on the potential benefits of using video technology suggests it might be a helpful strategy for early labor support. This study examined women's perspectives on the potential use of this technology.

METHODS

Focus groups and individual interviews were conducted with 23 English-speaking women who experienced spontaneous labor within the last year. The recordings were transcribed verbatim. Content analysis was used to interpret women's perceptions.

RESULTS

The women identified potential advantages of video technology in early labor connected to the major theme of being able to see, which could enable closer human connections between the intrapartum care provider, the woman, and her partner, as well as better assessments of labor. This human connection was integral to enhancing empathy and building confidence. Concerns about using video calls during early labor at home focused on privacy issues and the need to practice beforehand. Concerns about privacy depended upon having a prior relationship with the intrapartum care provider and women being able to decide if they wanted to use the technology.

DISCUSSION

One way of optimizing the experience of staying home in early labor and overall satisfaction with the birth experience may be with video technology, which could offer enhancements over traditional telephone triage.

Describing latent phase duration and associated characteristics among 1281 low-risk women in spontaneous labor

BACKGROUND

Recent research suggests that latent phase of labor may terminate at 6 rather than 4 centimeters of cervical dilation. The objectives of this study were to: (a) characterize duration of the latent phase of labor among term, low-risk, United States women in spontaneous labor using the women's self-identified onset; and (b) quantify associations between demographic and maternal/newborn health characteristics and the duration of the latent phase.

METHODS

This prospective study (n = 1281) described the duration of the latent phase of labor in hours, stratified by parity at the mean, median, and 80th, 90th, and 95th percentiles. The duration of the latent phase was compared for each characteristic using t tests or Wilcoxon rank-sum tests and regression models that controlled for confounders.

RESULTS

In this sample of predominantly white, healthy women, duration of the latent phase of labor was longer than described in previous studies: The median duration was 9.0 hours and mean duration was 11.8 hours in nulliparous women. The median duration was 6.8 hours and mean duration was 9.3 hours in multiparous women. Among nulliparous women, longer duration was seen in women whose fetus was in a malposition. Among multiparous women, longer durations were noted in women with chorioamnionitis and those who gave birth between 41 and 41 + 6 weeks' gestation (vs between 40 and 40 + 6 weeks' gestation).

CONCLUSIONS

The latent phase of labor may be longer than previously estimated. Contemporary estimates of latent phase of labor duration will help women and providers accurately anticipate, prepare, and cope during spontaneous labor.

Women's Prenatal and Labor Experiences in a Hospital With an Early-Labor Lounge

OBJECTIVE

To evaluate the information that women with low-risk pregnancies received during the prenatal period about latent labor and the early-labor lounge (ELL) and their subsequent use of the ELL.

DESIGN

Cross-sectional design with survey.

SETTING/LOCAL PROBLEM

Community hospital in the northeastern United States with a low-risk cesarean birth rate of 33%, which exceeds the national target rate of 23.9%.

PARTICIPANTS

Low-risk, nulliparous, pregnant women with a term singleton vertex fetus at hospital admission (N = 67).

INTERVENTION/MEASUREMENTS

An electronic survey was administered before hospital discharge following birth. The survey assessed prenatal education, use of the ELL, admission characteristics, and birth satisfaction. Descriptive analysis was used.

RESULTS

Nearly half (43.9%) of the women surveyed used the ELL. ELL users received prenatal care (72.3%), knew signs of active labor (93.1%), and had a cesarean birth rate of 7.1%. Significantly greater proportions of women prenatally cared for by midwives reported knowledge of the signs of early labor (100% vs. 80%; χ² = 4.4, p = .04) and of the availability of the ELL (18.2% vs. 70.6%; χ² = 15.2, p < .001). A range of activities were offered in the ELL, and at least 75% of women indicated that all activities were helpful during latent labor. Birth satisfaction scores, measured on a scale of 0 to 40, with 40 indicating greatest satisfaction, ranged from 22 to 35 among ELL participants.

CONCLUSION

An ELL is a care innovation that hospitals can consider for providing support to women with low-risk pregnancies during the latent phase of labor. Women who used the ELL reported feeling that it provided guidance and support. An ELL is a woman-centered option for delayed admission.