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Zang Y, Hu Y, Lu H. Effects of different techniques during the second stage of labour on reducing perineal laceration: An overview of systematic reviews. J Clin Nurs 2023; 32:996-1013. [PMID: 35253295 DOI: 10.1111/jocn.16276] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/25/2022] [Accepted: 02/21/2022] [Indexed: 12/28/2022]
Abstract
AIM AND OBJECTIVE To summarize the evidence on the effects of different techniques during the second stage of labour on reducing perineal laceration depending on available systematic reviews to provide optimal evidence for decision-making. BACKGROUND Preventing perineal laceration has been considered an important part of improving women's health. Various techniques have been used to prevent perineal laceration during the second stage of labour. However, systematic reviews evaluating the effects of different techniques on reducing perineal laceration show inconsistent results. DESIGN Overview of systematic reviews. METHODS Five English and four Chinese databases were systematically searched for relevant systematic reviews and meta-analyses published between 1 January 2016 and 31 August 2021. The quality of the included reviews was assessed by the AMSTAR 2 tool. A narrative synthesis was conducted to report the results of moderate-to-high quality systematic reviews. The overview was reported according to the PRISMA statement. RESULTS Eighteen reviews were included, of which four reviews had moderate-to-high methodological quality. Perineal massage and warm compresses significantly decreased the incidence of third- or fourth-degree perineal laceration (moderate-quality evidence). Hands-off technique had no impact on perineal laceration (low-to-moderate quality evidence). Ritgen's manoeuvre could reduce the incidence of first-degree perineal laceration but increase the incidence of second-degree perineal laceration (very low-quality evidence). Spontaneous pushing (low-quality evidence) and delayed pushing (moderate-quality evidence) had no impact on the incidence of third- or fourth-degree perineal laceration. Upright positions did not increase the risk of third- or fourth-degree perineal laceration (very low- to low-quality evidence) but increased the risk of second-degree perineal laceration for women without epidural analgesia (low-quality evidence). CONCLUSIONS Perineal massage and warm compresses could be the better choice for preventing perineal laceration in the second stage of labour. RELEVANCE TO CLINICAL PRACTICE Midwives and obstetricians could use perineal massage and warm compresses to prevent perineal laceration and should consider women's preferences and experience with perineal techniques.
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Affiliation(s)
- Yu Zang
- School of Nursing, Hebei Medical University, Shijiazhuang, China
| | - Yinchu Hu
- School of Nursing, Peking University, Beijing, China
| | - Hong Lu
- School of Nursing, Peking University, Beijing, China
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Cheng Q, Zhang W, Lu Y, Chen J, Tian H. Ropivacaine vs. levobupivacaine: Analgesic effect of combined spinal-epidural anesthesia during childbirth and effects on neonatal Apgar scores, as well as maternal vital signs. Exp Ther Med 2019; 18:2307-2313. [PMID: 31410181 DOI: 10.3892/etm.2019.7776] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 04/05/2019] [Indexed: 12/26/2022] Open
Abstract
The present study aimed to investigate and compare the analgesic effect and safety of ropivacaine or levobupivacaine in combined spinal-epidural anesthesia during childbirth and their effects on neonatal Apgar scores, as well as maternal and neonatal vital signs. A total of 615 maternal patients undergoing labor between April 2016 and March 2017 were divided into two groups according to the analgesic used for combined spinal-epidural anesthesia during childbirth: The ropivacaine group (n=318) and the levobupivacaine group (n=297). The onset time of analgesia in the two groups was determined and the pain score on the visual analog scale was assessed at the time of delivery (T3). At pre-analgesia, 30 min after analgesia (T2), at T3 and during maternal wound suturing (T4), the systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) were assessed. The cesarean section rate, neonatal 1- and 5-min Apgar scores and neonatal asphyxia at T4 were also determined. The onset time of analgesia in the ropivacaine group was significantly reduced compared with that in the levobupivacaine group (P<0.05). At T2 and T4, the SBP was significantly higher in the levobupivacaine group than that in the ropivacaine group (P<0.05). At T2, T3 and T4, the DBP was significantly lower in the levobupivacaine group compared with those in the ropivacaine group (P<0.05). At T2, the HR was significantly lower in the levobupivacaine group than that in the ropivacaine group (P<0.05). The cesarean section rate was significantly lower in the ropivacaine group compared with that in the levobupivacaine group [4.09% (n=13) vs. 22.89% (n=68); P<0.01]. In conclusion, the use of combined spinal-epidural anesthesia with ropivacaine or levobupivacaine has an excellent analgesic effect during childbirth. However, compared with levobupivacaine, ropivacaine for labor analgesia had a faster onset and a lesser impact on maternal vital signs, and was associated with a reduced maternal cesarean section rate among patients who did not opt for cesarean section in the beginning; therefore, it is useful in clinical practice.
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Affiliation(s)
- Qiuju Cheng
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong 510623, P.R. China
| | - Weiqiang Zhang
- Department of Gynecology and Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong 510623, P.R. China
| | - Yanling Lu
- Department of Gynecology and Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong 510623, P.R. China
| | - Jinhai Chen
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong 510623, P.R. China
| | - Hang Tian
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong 510623, P.R. China
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Cummins G, Kremer J, Bernassau A, Brown A, Bridle HL, Schulze H, Bachmann TT, Crichton M, Denison FC, Desmulliez MPY. Sensors for Fetal Hypoxia and Metabolic Acidosis: A Review. SENSORS (BASEL, SWITZERLAND) 2018; 18:E2648. [PMID: 30104478 PMCID: PMC6111374 DOI: 10.3390/s18082648] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 07/30/2018] [Accepted: 08/02/2018] [Indexed: 12/11/2022]
Abstract
This article reviews existing clinical practices and sensor research undertaken to monitor fetal well-being during labour. Current clinical practices that include fetal heart rate monitoring and fetal scalp blood sampling are shown to be either inadequate or time-consuming. Monitoring of lactate in blood is identified as a potential alternative for intrapartum fetal monitoring due to its ability to distinguish between different types of acidosis. A literature review from a medical and technical perspective is presented to identify the current advancements in the field of lactate sensors for this application. It is concluded that a less invasive and a more continuous monitoring device is required to fulfill the clinical needs of intrapartum fetal monitoring. Potential specifications for such a system are also presented in this paper.
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Affiliation(s)
- Gerard Cummins
- Institute of Sensors, Signals and Systems, Heriot-Watt University, Riccarton EH14 4AS, Scotland, UK.
| | - Jessica Kremer
- Institute of Sensors, Signals and Systems, Heriot-Watt University, Riccarton EH14 4AS, Scotland, UK.
| | - Anne Bernassau
- Institute of Sensors, Signals and Systems, Heriot-Watt University, Riccarton EH14 4AS, Scotland, UK.
| | - Andrew Brown
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, Scotland, UK.
| | - Helen L Bridle
- Institute of Sensors, Signals and Systems, Heriot-Watt University, Riccarton EH14 4AS, Scotland, UK.
| | - Holger Schulze
- Division of Infection and Pathway Medicine, Edinburgh Medical School, The Chancellor's Building, The University of Edinburgh, Edinburgh EH16 4SB, Scotland, UK.
| | - Till T Bachmann
- Division of Infection and Pathway Medicine, Edinburgh Medical School, The Chancellor's Building, The University of Edinburgh, Edinburgh EH16 4SB, Scotland, UK.
| | - Michael Crichton
- Institute of Mechanical, Processing and Energy Engineering, Heriot-Watt University, Riccarton EH14 4AS, Scotland, UK.
| | - Fiona C Denison
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, Scotland, UK.
| | - Marc P Y Desmulliez
- Institute of Sensors, Signals and Systems, Heriot-Watt University, Riccarton EH14 4AS, Scotland, UK.
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Dur-e-shahwar, Ahmed I, Amerjee A, Hoodbhoy Z. Comparison of neonatal outcomes between category-1 and non-category-1 Primary Emergency Cesarean Section: A retrospective record review in a tertiary care hospital. Pak J Med Sci 2018; 34:823-827. [PMID: 30190735 PMCID: PMC6115571 DOI: 10.12669/pjms.344.14496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 07/03/2018] [Accepted: 07/05/2018] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To compare neonatal outcomes between Category-1 and Non-Category-1 Primary Emergency Cesarean Section. METHODS This was a retrospective analysis, conducted at Aga Khan University Hospital Karachi from January 1st 2016 till December 31st 2016. Non-probability purposive sampling technique was used. A sample size of 375 patients who had primary Emergency Caesarean Section (Em-CS) was identified by keeping CS rate of 41.5% and 5% bond on error. Data was collected from labor ward, operating theatre and neonatal ward records by using structured questionnaire. RESULTS In the current study, out of 375 participants who underwent primary Em-CS; majority (89.3%) were booked cases. Two-hundred-eighty-two (75.2%) were primiparous women. Two hundred and thirty (61.3%) were at term and 145(38.7%) were preterm. The main indication among Category-1 CS was fetal distress (15.7%). For Non-Category-1 CS, non-progress of labour (45.1%) was the leading cause of abdominal delivery. Except for APGAR score at one minute (p value = 0.048), no other variables were statistically significant when neonatal outcomes were compared among Category-1 and Non-Category-1 CS. CONCLUSION In this study, fetal distress and non-progress of labor were the main indications for Category-1 and Non-Category-1 CS respectively. We did not find statistically significant association between indications of Em CS and neonatal outcomes. However further prospective studies are required to confirm this association.
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Affiliation(s)
- Dur-e-shahwar
- Dr. Dur-e-Shahwar, FCPS. Department of Obstetrics and Gynaecology, The Aga Khan University Hospital, Karachi, Pakistan
| | - Iffat Ahmed
- Dr. Iffat Ahmed, FCPS. Department of Obstetrics and Gynaecology, The Aga Khan University Hospital, Karachi, Pakistan
| | - Azra Amerjee
- Dr. Azra Amerjee, FCPS; MCPS HPE; PGD Bioethics. Department of Obstetrics and Gynaecology, The Aga Khan University Hospital, Karachi, Pakistan
| | - Zahra Hoodbhoy
- Zahra Hoodbhoy, Department of Obstetrics and Gynaecology, The Aga Khan University Hospital, Karachi, Pakistan
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Jang W, Flatley C, Greer RM, Kumar S. Comparison between public and private sectors of care and disparities in adverse neonatal outcomes following emergency intrapartum cesarean at term - A retrospective cohort study. PLoS One 2017; 12:e0187040. [PMID: 29149182 PMCID: PMC5693444 DOI: 10.1371/journal.pone.0187040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 10/10/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Perinatal outcomes may be influenced by a variety of factors including maternal demographics and medical condition as well as socio-economic status. The evidence for disparities in health outcomes stratified by type of care (public or private) is lacking. The aim of this study was to investigate short term neonatal outcomes following category 1 and 2 emergency cesareans at term between publicly and privately funded women at a single major tertiary centre in Australia. Category 1-immediate threat to life (maternal or fetal); Category 2-maternal or fetal compromise that is not immediately life-threatening. METHODS This was a retrospective, cross sectional study of 61355 term singleton babies born at the Mater Mother's Hospital in Brisbane, Australia in 2007-2014. We collected data from the hospital's maternity database and compared maternal demographics, indications for cesarean and neonatal outcomes for publicly and privately funded women. RESULTS Over the study period there were 32477 public and 28878 private, term singleton births. Compared to the publicly funded cohort, privately insured women were older, had lower BMI, were of Caucasian ethnicity, Australian born, nulliparous, had shorter labors and had lower rates of hypertensive disorders and diabetes. The most common indications for category 1 and category 2 cesareans in combination were non-reassuring fetal status followed by failure to progress in labor and malpresentation. For both category 1 and 2 cesareans, neonatal outcomes (Apgar score <7 at 5 minutes, abnormal cord gases, Neonatal Critical Care Unit admission rates, rates of severe respiratory distress and jaundice) were significantly worse in the publicly funded compared to the privately insured cohort Multivariate analyses controlling for maternal age, ethnicity, country of birth, parity, hypertension, diabetes mellitus, gestational age at birth and length of labour confirmed that private insurance status was highly protective for the perinatal outcomes of Apgar score <7 at 5 minutes (aOR 0.26, 95% CI 0.13-0.55), admission to NCCU (OR 0.51, 95% CI 0.30-0.92) and respiratory distress (aOR 0.60, 95% CI 0.41-0.86). CONCLUSION Birth in the private health sector was inversely associated with adverse neonatal outcomes following category 1 and 2 cesareans.
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Affiliation(s)
- Woonji Jang
- Mater Research Institute—University of Queensland, South Brisbane, Queensland, Australia
| | - Christopher Flatley
- Mater Research Institute—University of Queensland, South Brisbane, Queensland, Australia
| | - Ristan M. Greer
- Mater Research Institute—University of Queensland, South Brisbane, Queensland, Australia
| | - Sailesh Kumar
- Mater Research Institute—University of Queensland, South Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Denison FC, Norrie J, Lawton J, Norman JE, Scotland G, McPherson GC, McDonald A, Forrest M, Hudson J, Brewin J, Peace M, Clarkson C, Brook-Smith S, Morrow S, Hallowell N, Hodges L, Carruthers KF. A pragmatic group sequential, placebo-controlled, randomised trial to determine the effectiveness of glyceryl trinitrate for retained placenta (GOT-IT): a study protocol. BMJ Open 2017; 7:e017134. [PMID: 28928192 PMCID: PMC5623532 DOI: 10.1136/bmjopen-2017-017134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/29/2017] [Accepted: 07/03/2017] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION A retained placenta is diagnosed when the placenta is not delivered following delivery of the baby. It is a major cause of postpartum haemorrhage and treated by the operative procedure of manual removal of placenta (MROP). METHODS AND ANALYSIS The aim of this pragmatic, randomised, placebo-controlled, double-blind UK-wide trial, with an internal pilot and nested qualitative research to adjust strategies to refine delivery of the main trial, is to determine whether sublingual glyceryl trinitrate (GTN) is (or is not) clinically and cost-effective for (medical) management of retained placenta. The primary clinical outcome is need for MROP, defined as the placenta remaining undelivered 15 min poststudy treatment and/or being required within 15 min of treatment due to safety concerns. The primary safety outcome is measured blood loss between administration of treatment and transfer to the postnatal ward or other clinical area. The primary patient-sided outcome is satisfaction with treatment and a side effect profile. The primary economic outcome is net incremental costs (or cost savings) to the National Health Service of using GTN versus standard practice. Secondary outcomes are being measured over a range of clinical and economic domains. The primary outcomes will be analysed using linear models appropriate to the distribution of each outcome. Health service costs will be compared with multiple trial outcomes in a cost-consequence analysis of GTN versus standard practice. ETHICS AND DISSEMINATION Ethical approval has been obtained from the North-East Newcastle & North Tyneside 2 Research Ethics Committee (13/NE/0339). Dissemination plans for the trial include the Health Technology Assessment Monograph, presentation at international scientific meetings and publication in high-impact, peer-reviewed journals. TRIAL REGISTRATION NUMBER ISCRTN88609453; Pre-results.
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Affiliation(s)
- Fiona C Denison
- Tommy's Centre for Maternal and Fetal Health Research, Medical Research Council Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - John Norrie
- The Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Julia Lawton
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Jane E Norman
- Tommy's Centre for Maternal and Fetal Health Research, Medical Research Council Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Graham Scotland
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Gladys C McPherson
- The Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Alison McDonald
- The Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Mark Forrest
- The Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jemma Hudson
- The Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Mathilde Peace
- Tommy's Centre for Maternal and Fetal Health Research, Medical Research Council Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Cynthia Clarkson
- Tommy's Centre for Maternal and Fetal Health Research, Medical Research Council Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Sheonagh Brook-Smith
- Simpson's Centre for Reproductive Health, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Susan Morrow
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Nina Hallowell
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
- Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Laura Hodges
- Tommy's Centre for Maternal and Fetal Health Research, Medical Research Council Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Kathryn F Carruthers
- Tommy's Centre for Maternal and Fetal Health Research, Medical Research Council Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
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Lawton J, Hallowell N, Snowdon C, Norman JE, Carruthers K, Denison FC. Written versus verbal consent: a qualitative study of stakeholder views of consent procedures used at the time of recruitment into a peripartum trial conducted in an emergency setting. BMC Med Ethics 2017; 18:36. [PMID: 28539111 PMCID: PMC5443362 DOI: 10.1186/s12910-017-0196-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 05/14/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Obtaining prospective written consent from women to participate in trials when they are experiencing an obstetric emergency is challenging. Alternative consent pathways, such as gaining verbal consent at enrolment followed, later, by obtaining written consent, have been advocated by some clinicians and bioethicists but have received little empirical attention. We explored women's and staff views about the consent procedures used during the internal pilot of a trial (GOT-IT), where the protocol permitted staff to gain verbal consent at recruitment. METHODS Interviews with staff (n = 27) and participating women (n = 22). Data were analysed thematically and interviews were cross-compared to identify differences and similarities in participants' views about the consent procedures used. RESULTS Women and some staff highlighted benefits to obtaining verbal consent at trial enrolment, including expediting recruitment and reducing the burden on those left exhausted by their births. However, most staff with direct responsibility for taking consent expressed extreme reluctance to proceed with enrolment until they had obtained written consent, despite being comfortable using verbal procedures in their clinical practice. To account for this resistance, staff drew a strong distinction between research and clinical care and suggested that a higher level of consent was needed when recruiting into trials. In doing so, staff emphasised the need to engage women in reflexive decision-making and highlighted the role that completing the consent form could play in enabling and evidencing this process. While most staff cited their ethical responsibilities to women, they also voiced concerns that the absence of a signed consent form at recruitment could expose them to greater risk of litigation were an individual to experience a complication during the trial. Inexperience of recruiting into peripartum trials and limited availability of staff trained to take consent also reinforced preferences for obtaining written consent at recruitment. CONCLUSIONS While alternative consent pathways have an important role to play in advancing emergency medicine research, and may be appreciated by potential recruits, they may give rise to unintended ethical and logistical challenges for staff. Staff would benefit from training and support to increase their confidence and willingness to recruit into trials using alternative consent pathways. TRIAL REGISTRATION This qualitative research was undertaken as part of the GOT-IT Trial (trial registration number: ISCRTN 88609453 ). Date of registration 26/03/2014.
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Affiliation(s)
- J. Lawton
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - N. Hallowell
- Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - C. Snowdon
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - J. E. Norman
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - K. Carruthers
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - F. C. Denison
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
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Devane D, Lalor JG, Daly S, McGuire W, Cuthbert A, Smith V. Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing. Cochrane Database Syst Rev 2017; 1:CD005122. [PMID: 28125772 PMCID: PMC6464914 DOI: 10.1002/14651858.cd005122.pub5] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The admission cardiotocograph (CTG) is a commonly used screening test consisting of a short (usually 20 minutes) recording of the fetal heart rate (FHR) and uterine activity performed on the mother's admission to the labour ward. This is an update of a review published in 2012. OBJECTIVES To compare the effects of admission cardiotocography with intermittent auscultation of the FHR on maternal and infant outcomes for pregnant women without risk factors on their admission to the labour ward. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register to 30 November 2016 and we planned to review the reference list of retrieved papers SELECTION CRITERIA All randomised and quasi-randomised trials comparing admission CTG with intermittent auscultation of the FHR for pregnant women between 37 and 42 completed weeks of pregnancy and considered to be at low risk of intrapartum fetal hypoxia and of developing complications during labour. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial eligibility and quality, and extracted data. Data were checked for accuracy. MAIN RESULTS We included no new trials in this update. We included four trials involving more than 13,000 women which were conducted in the UK and Ireland and included women in labour. Three trials were funded by the hospitals where the trials took place and one trial was funded by the Scottish government. No declarations of interest were made in two trials; the remaining two trials did not mention declarations of interest. Overall, the studies were assessed as low risk of bias. Results reported in the 2012 review remain unchanged.Although not statistically significant using a strict P < 0.05 criterion, data were consistent with women allocated to admission CTG having, on average, a higher probability of an increase in incidence of caesarean section than women allocated to intermittent auscultation (risk ratio (RR) 1.20, 95% confidence interval (CI) 1.00 to 1.44, 4 trials, 11,338 women, I² = 0%, moderate quality evidence). There was no clear difference in the average treatment effect across included trials between women allocated to admission CTG and women allocated to intermittent auscultation in instrumental vaginal birth (RR 1.10, 95% CI 0.95 to 1.27, 4 trials, 11,338 women, I² = 38%, low quality evidence) and perinatal mortality rate (RR 1.01, 95% CI 0.30 to 3.47, 4 trials, 11,339 infants, I² = 0%, moderate quality evidence).Women allocated to admission CTG had, on average, higher rates of continuous electronic fetal monitoring during labour (RR 1.30, 95% CI 1.14 to 1.48, 3 trials, 10,753 women, I² = 79%, low quality evidence) and fetal blood sampling (RR 1.28, 95% CI 1.13 to 1.45, 3 trials, 10,757 women, I² = 0%) than women allocated to intermittent auscultation. There were no differences between groups in other secondary outcome measures including incidence and severity of hypoxic ischaemic encephalopathy (incidence only reported) (RR 1.19, 95% CI 0.37 to 3.90; 2367 infants; 1 trial; very low quality evidence) and incidence of seizures in the neonatal period (RR 0.72, 95% CI 0.32 to 1.61; 8056 infants; 1 trial; low quality evidence). There were no data reported for severe neurodevelopmental disability assessed at greater than, or equal to, 12 months of age. AUTHORS' CONCLUSIONS Contrary to continued use in some clinical areas, we found no evidence of benefit for the use of the admission CTG for low-risk women on admission in labour.Furthermore, the probability is that admission CTG increases the caesarean section rate by approximately 20%. The data lacked power to detect possible important differences in perinatal mortality. However, it is unlikely that any trial, or meta-analysis, will be adequately powered to detect such differences. The findings of this review support recommendations that the admission CTG not be used for women who are low risk on admission in labour. Women should be informed that admission CTG is likely associated with an increase in the incidence of caesarean section without evidence of benefit.Evidence quality ranged from moderate to very low, with downgrading decisions based on imprecision, inconsistency and a lack of blinding for participants and personnel. All four included trials were conducted in developed Western European countries. One additional study is ongoing.The usefulness of the findings of this review for developing countries will depend on FHR monitoring practices. However, an absence of benefit and likely harm associated with admission CTG will have relevance for countries where questions are being asked about the role of the admission CTG.Future studies evaluating the effects of the admission CTG should consider including women admitted with signs of labour and before a formal diagnosis of labour. This would include a cohort of women currently having admission CTGs and not included in current trials.
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Affiliation(s)
- Declan Devane
- National University of Ireland GalwaySchool of Nursing and MidwiferyUniversity RoadGalwayIreland
| | - Joan G Lalor
- Trinity College DublinSchool of Nursing and Midwifery24 D'Olier StreetDublinIreland2
| | - Sean Daly
- Coombe Women & Infants University HospitalDolphin's BarnDublin 8Ireland
| | - William McGuire
- University of YorkCentre for Reviews and DisseminationYorkY010 5DDUK
| | - Anna Cuthbert
- University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Valerie Smith
- Trinity College DublinSchool of Nursing and Midwifery24 D'Olier StreetDublinIreland2
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Symon A, Pringle J, Downe S, Hundley V, Lee E, Lynn F, McFadden A, McNeill J, Renfrew MJ, Ross-Davie M, van Teijlingen E, Whitford H, Alderdice F. Antenatal care trial interventions: a systematic scoping review and taxonomy development of care models. BMC Pregnancy Childbirth 2017; 17:8. [PMID: 28056877 PMCID: PMC5216531 DOI: 10.1186/s12884-016-1186-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 12/07/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antenatal care models vary widely around the world, reflecting local contexts, drivers and resources. Randomised controlled trials (RCTs) have tested the impact of multi-component antenatal care interventions on service delivery and outcomes in many countries since the 1980s. Some have applied entirely new schemes, while others have modified existing care delivery approaches. Systematic reviews (SRs) indicate that some specific antenatal interventions are more effective than others; however the causal mechanisms leading to better outcomes are poorly understood, limiting implementation and future research. As a first step in identifying what might be making the difference we conducted a scoping review of interventions tested in RCTs in order to establish a taxonomy of antenatal care models. METHODS A protocol-driven systematic search was undertaken of databases for RCTs and SRs reporting antenatal care interventions. Results were unrestricted by time or locality, but limited to English language. Key characteristics of both experimental and control interventions in the included trials were mapped using SPIO (Study design; Population; Intervention; Outcomes) criteria and the intervention and principal outcome measures were described. Commonalities and differences between the components that were being tested in each study were identified by consensus, resulting in a comprehensive description of emergent models for antenatal care interventions. RESULTS Of 13,050 articles retrieved, we identified 153 eligible articles including 130 RCTs in 34 countries. The interventions tested in these trials varied from the number of visits to the location of care provision, and from the content of care to the professional/lay group providing that care. In most studies neither intervention nor control arm was well described. Our analysis of the identified trials of antenatal care interventions produced the following taxonomy: Universal provision model (for all women irrespective of health state or complications); Restricted 'lower-risk'-based provision model (midwifery-led or reduced/flexible visit approach for healthy women); Augmented provision model (antenatal care as in Universal provision above but augmented by clinical, educational or behavioural intervention); Targeted 'higher-risk'-based provision model (for woman with defined clinical or socio-demographic risk factors). The first category was most commonly tested in low-income countries (i.e. resource-poor settings), particularly in Asia. The other categories were tested around the world. The trials included a range of care providers, including midwives, nurses, doctors, and lay workers. CONCLUSIONS Interventions can be defined and described in many ways. The intended antenatal care population group proved the simplest and most clinically relevant way of distinguishing trials which might otherwise be categorised together. Since our review excluded non-trial interventions, the taxonomy does not represent antenatal care provision worldwide. It offers a stable and reproducible approach to describing the purpose and content of models of antenatal care which have been tested in a trial. It highlights a lack of reported detail of trial interventions and usual care processes. It provides a baseline for future work to examine and test the salient characteristics of the most effective models, and could also help decision-makers and service planners in planning implementation.
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Affiliation(s)
- Andrew Symon
- Mother & Infant Research Unit, University of Dundee, DD1 4HJ Dundee, UK
| | - Jan Pringle
- School of Nursing & Health Sciences, University of Dundee, DD1 4HJ Dundee, UK
| | - Soo Downe
- School of Health, Brook Building, University of Central Lancashire, Preston, PR1 2HE UK
| | - Vanora Hundley
- Centre for Midwifery, Maternal & Perinatal Health, Faculty of Health & Social Sciences, Bournemouth University, BU1 3LH Poole, UK
| | - Elaine Lee
- Mother & Infant Research Unit, University of Dundee, DD1 4HJ Dundee, UK
| | - Fiona Lynn
- School of Nursing & Midwifery, Queens University, Belfast, BT9 7BL UK
| | - Alison McFadden
- Mother & Infant Research Unit, University of Dundee, DD1 4HJ Dundee, UK
| | - Jenny McNeill
- School of Nursing & Midwifery, Queens University, Belfast, BT9 7BL UK
| | - Mary J Renfrew
- Mother & Infant Research Unit, University of Dundee, DD1 4HJ Dundee, UK
| | - Mary Ross-Davie
- Maternal & Child Health, NHS Education for Scotland, Edinburgh, EH3 9DN UK
| | - Edwin van Teijlingen
- Centre for Midwifery, Maternal & Perinatal Health, Faculty of Health & Social Sciences, Bournemouth University, BU1 3LH Poole, UK
| | - Heather Whitford
- Mother & Infant Research Unit, University of Dundee, DD1 4HJ Dundee, UK
| | - Fiona Alderdice
- School of Nursing & Midwifery, Queens University, Belfast, BT9 7BL UK
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10
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Determination of Normal Ranges of Shock Index and Other Haemodynamic Variables in the Immediate Postpartum Period: A Cohort Study. PLoS One 2016; 11:e0168535. [PMID: 27997586 PMCID: PMC5173287 DOI: 10.1371/journal.pone.0168535] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 12/02/2016] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To determine the normal ranges of vital signs, including blood pressure (BP), mean arterial pressure (MAP), heart rate (HR) and shock index (SI) (HR/systolic BP), in the immediate postpartum period to inform the development of robust obstetric early warning scores. STUDY DESIGN We conducted a secondary analysis of a prospective observational cohort study evaluating vital signs collected within one hour following delivery in women with estimated blood loss (EBL) <500ml (316 women) delivering at a UK tertiary centre over a one-year period. Simple and multiple linear regression were used to explore associations of demographic and obstetric factors with SI. RESULTS Median (90% reference range) was 120 (100-145) for systolic BP, 75 (58-90) for diastolic BP, 90 (73-108) for MAP, 81 (61-102) for HR, and 0.66 (0.52-0.89) for SI. Third stage Syntometrine® administration was associated with a 0.03 decrease in SI (p = 0.035) and epidural use with a 0.05 increase (p = 0.003). No other demographic or obstetric factors were associated with a change in shock index in this cohort. CONCLUSION This is the first study to determine normal ranges of maternal BP, MAP, HR and SI within one hour of birth, a time of considerable haemodynamic adjustment, with minimal effect of demographic and obstetric factors demonstrated. The lower 90% reference point for systolic BP and upper 90% reference point for HR correspond to triggers used to recognise shock in obstetric practice, as do the upper 90% reference points for systolic and diastolic BP for obstetric hypertensive triggers. The SI upper limit of 0.89 in well postpartum women supports current literature suggesting a threshold of 0.9 as indicating increased risk of adverse outcomes.
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11
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Symon A, Pringle J, Cheyne H, Downe S, Hundley V, Lee E, Lynn F, McFadden A, McNeill J, Renfrew MJ, Ross-Davie M, van Teijlingen E, Whitford H, Alderdice F. Midwifery-led antenatal care models: mapping a systematic review to an evidence-based quality framework to identify key components and characteristics of care. BMC Pregnancy Childbirth 2016; 16:168. [PMID: 27430506 PMCID: PMC4949880 DOI: 10.1186/s12884-016-0944-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 06/09/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Implementing effective antenatal care models is a key global policy goal. However, the mechanisms of action of these multi-faceted models that would allow widespread implementation are seldom examined and poorly understood. In existing care model analyses there is little distinction between what is done, how it is done, and who does it. A new evidence-informed quality maternal and newborn care (QMNC) framework identifies key characteristics of quality care. This offers the opportunity to identify systematically the characteristics of care delivery that may be generalizable across contexts, thereby enhancing implementation. Our objective was to map the characteristics of antenatal care models tested in Randomised Controlled Trials (RCTs) to a new evidence-based framework for quality maternal and newborn care; thus facilitating the identification of characteristics of effective care. METHODS A systematic review of RCTs of midwifery-led antenatal care models. Mapping and evaluation of these models' characteristics to the QMNC framework using data extraction and scoring forms derived from the five framework components. Paired team members independently extracted data and conducted quality assessment using the QMNC framework and standard RCT criteria. RESULTS From 13,050 citations initially retrieved we identified 17 RCTs of midwifery-led antenatal care models from Australia (7), the UK (4), China (2), and Sweden, Ireland, Mexico and Canada (1 each). QMNC framework scores ranged from 9 to 25 (possible range 0-32), with most models reporting fewer than half the characteristics associated with quality maternity care. Description of care model characteristics was lacking in many studies, but was better reported for the intervention arms. Organisation of care was the best-described component. Underlying values and philosophy of care were poorly reported. CONCLUSIONS The QMNC framework facilitates assessment of the characteristics of antenatal care models. It is vital to understand all the characteristics of multi-faceted interventions such as care models; not only what is done but why it is done, by whom, and how this differed from the standard care package. By applying the QMNC framework we have established a foundation for future reports of intervention studies so that the characteristics of individual models can be evaluated, and the impact of any differences appraised.
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Affiliation(s)
- Andrew Symon
- />Mother and Infant Research Unit, University of Dundee, Dundee, DD1 4HJ UK
| | - Jan Pringle
- />School of Nursing & Health Sciences, University of Dundee, Dundee, DD1 4HJ UK
| | - Helen Cheyne
- />NMAHP Research Unit, University of Stirling, Stirling, UK
| | - Soo Downe
- />School of Health, Brook Building, University of Central Lancashire, Preston, PR1 2HE UK
| | - Vanora Hundley
- />Centre for Midwifery, Maternal & Perinatal Health, Faculty of Health & Social Sciences, Bournemouth University, Bournemouth, BU1 3LH UK
| | - Elaine Lee
- />Mother and Infant Research Unit, University of Dundee, Dundee, DD1 4HJ UK
| | - Fiona Lynn
- />School of Nursing and Midwifery, Queens University Belfast, Belfast, BT9 7BL UK
| | - Alison McFadden
- />Mother and Infant Research Unit, University of Dundee, Dundee, DD1 4HJ UK
| | - Jenny McNeill
- />School of Nursing and Midwifery, Queens University Belfast, Belfast, BT9 7BL UK
| | - Mary J Renfrew
- />Mother and Infant Research Unit, University of Dundee, Dundee, DD1 4HJ UK
| | - Mary Ross-Davie
- />Maternal and Child Health, NHS Education for Scotland, Edinburgh, EH3 9DN UK
| | - Edwin van Teijlingen
- />Centre for Midwifery, Maternal & Perinatal Health, Faculty of Health & Social Sciences, Bournemouth University, Bournemouth, BU1 3LH UK
| | - Heather Whitford
- />Mother and Infant Research Unit, University of Dundee, Dundee, DD1 4HJ UK
| | - Fiona Alderdice
- />School of Nursing and Midwifery, Queens University Belfast, Belfast, BT9 7BL UK
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12
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Rowe R, Li Y, Knight M, Brocklehurst P, Hollowell J. Maternal and perinatal outcomes in women planning vaginal birth after caesarean (VBAC) at home in England: secondary analysis of the Birthplace national prospective cohort study. BJOG 2016; 123:1123-32. [PMID: 26213223 PMCID: PMC5014182 DOI: 10.1111/1471-0528.13546] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare vaginal birth rates in women planning vaginal birth after caesarean (VBAC) at home versus in an obstetric unit (OU) and explore transfer rates in women planning home VBAC. DESIGN Prospective cohort study. SETTING OUs and planned home births in England. POPULATION 1436 women planning VBAC in the Birthplace cohort, including 209 planning home VBAC. METHODS We used Poisson regression to calculate relative risks adjusted for maternal characteristics. MAIN OUTCOME MEASURES MAIN OUTCOMES (i) vaginal birth and (ii) transfer from planned home birth to OU during labour or immediately after birth. SECONDARY OUTCOMES (i) composite of maternal blood transfusion or admission to higher level care, (ii) stillbirth or Apgar score <7 at 5 minutes, (iii) neonatal unit admission. RESULTS Planned VBAC at home was associated with a statistically significant increase in the chances of having a vaginal birth compared with planned VBAC in an OU (adjusted relative risk 1.15, 95% confidence interval 1.06-1.24). The risk of an adverse maternal outcome was around 2-3% in both settings, with a similar risk of an adverse neonatal outcome. Transfer rates were high (37%) and varied markedly by parity (para 1, 56.7% versus para 2+, 24.6%). CONCLUSION Women in the cohort who planned VBAC at home had an increased chance of a vaginal birth compared with those planning VBAC in an OU, but transfer rates were high, particularly for women with only one previous birth, and the risk of an adverse maternal or perinatal outcome was around 2-3%. No change in guidance can be recommended. TWEETABLE ABSTRACT Higher vaginal birth rates in planned VBAC at home versus in OU but 2-3% adverse outcomes and high transfer rate.
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Affiliation(s)
- R Rowe
- Policy Research Unit in Maternal Health and CareNational Perinatal Epidemiology UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Y Li
- Policy Research Unit in Maternal Health and CareNational Perinatal Epidemiology UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - M Knight
- Policy Research Unit in Maternal Health and CareNational Perinatal Epidemiology UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - P Brocklehurst
- Policy Research Unit in Maternal Health and CareNational Perinatal Epidemiology UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
- Institute for Women's HealthUniversity College LondonLondonUK
| | - J Hollowell
- Policy Research Unit in Maternal Health and CareNational Perinatal Epidemiology UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
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13
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Carlsson IM. Being in a safe and thus secure place, the core of early labour: A secondary analysis in a Swedish context. Int J Qual Stud Health Well-being 2016; 11:30230. [PMID: 27172510 PMCID: PMC4864843 DOI: 10.3402/qhw.v11.30230] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Early labour is the very first phase of the labour process and is considered to be a period of time when no professional attendance is needed. However there is a high frequency of women who seek care at the delivery wards during this phase. When a woman is admitted to the delivery ward, one role for midwives is to determine whether the woman is in established labour or not. If the woman is assessed as being in early labour she will probably then be advised to return home. This recommendation is made due to past research that found that the longer a woman is in hospital the higher the risk for complications for her and her child. Women have described how this situation leaves them in a vulnerable situation where their preferences are not always met and where they are not always included in the decision-making process. AIM The aim of this study was to generate a theory based on where a woman chooses to be during the early labour process and to increase our understanding about how experiences can differ from place to place. METHODS The method was a secondary analysis with grounded theory. The data used in the analysis was from two qualitative interview studies and 37 transcripts. CONCLUSION The findings revealed a substantive theory that women needed to be in a safe and thus secure place during early labour. This theory also describes the interplay between how women ascribed their meaning of childbirth as either a natural live event or a medical one, how this influenced where they wanted to be during early labour, and how that chosen place influenced their experiences of labour and birth.
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Affiliation(s)
- Ing-Marie Carlsson
- School of Health and Welfare, department of health and nursing, Halmstad University, Halmstad, Sweden;
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14
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Lawton J, Snowdon C, Morrow S, Norman JE, Denison FC, Hallowell N. Recruiting and consenting into a peripartum trial in an emergency setting: a qualitative study of the experiences and views of women and healthcare professionals. Trials 2016; 17:195. [PMID: 27066777 PMCID: PMC4827233 DOI: 10.1186/s13063-016-1323-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 04/01/2016] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Recruiting and consenting women to peripartum trials can be challenging as the women concerned may be anxious, in pain, and exhausted; there may also be limited time for discussion and decision-making to occur. To address these potential difficulties, we undertook a qualitative evaluation of the internal pilot of a trial (Got-it) involving women who had a retained placenta (RP). We explored the experiences and views of women and staff about the information and consent pathway used within the pilot, in order to provide recommendations for use in future peripartum trials involving recruitment in emergency situations. METHODS In-depth interviews were undertaken with staff (n = 27) and participating women (n = 22). Interviews were analysed thematically. The accounts of women and staff were compared to identify differences and similarities in their views about recruitment and consent procedures. RESULTS Women and staff regarded recruitment as having been straightforward and facilitated by the use of simplified (verbal and written) summaries of trial information. Both parties, however, conveyed discordant views about whether fully informed consent had been obtained. These differences in perspectives appeared to arise from the different factors and considerations impinging on women and staff at the time of recruitment. While staff placed emphasis on promoting understanding in the emergency situation of RP by imparting information in clear and succinct ways, women highlighted the experiential realities of their pre- and post-birthing situations, and how these had led to quick decisions being made without full engagement with the potential risks of trial participation. To facilitate informed consent, women suggested that trial information should be given during the antenatal period, and, in doing so, articulated a rights-based discourse. Staff, however, voiced opposition to this approach by emphasising a duty of care to all pregnant women, and raising concerns about causing undue distress to the majority of individuals who would not subsequently develop a RP. CONCLUSIONS By drawing upon the perspectives of women and staff involved in the same trial we have shown that they may operate within different experiential and ethical paradigms. In doing so, we argue for the potential benefits of drawing upon multiple perspectives when developing information and consent pathways used in future (peripartum) trials. TRIAL REGISTRATION ISCRTN 88609453 .
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Affiliation(s)
- Julia Lawton
- />Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Claire Snowdon
- />Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Susan Morrow
- />Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Jane E. Norman
- />MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Fiona C. Denison
- />MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Nina Hallowell
- />Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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15
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Iravani M, Janghorbani M, Zarean E, Bahrami M. Barriers to Implementing Evidence-Based Intrapartum Care: A Descriptive Exploratory Qualitative Study. IRANIAN RED CRESCENT MEDICAL JOURNAL 2016; 18:e21471. [PMID: 27175303 PMCID: PMC4863155 DOI: 10.5812/ircmj.21471] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 07/26/2014] [Accepted: 09/03/2014] [Indexed: 01/23/2023]
Abstract
BACKGROUND Evidence based practice is an effective strategy to improve the quality of obstetric care. Identification of barriers to adaptation of evidence-based intrapartum care is necessary and crucial to deliver high quality care to parturient women. OBJECTIVES The current study aimed to explore barriers to adaptation of evidence-based intrapartum care from the perspective of clinical groups that provide obstetric care in Iran. MATERIALS AND METHODS This descriptive exploratory qualitative research was conducted from 2013 to 2014 in fourteen state medical training centers in Iran. Participants were selected from midwives, specialists, and residents of obstetrics and gynecology, with a purposive sample and snowball method. Data were collected through face-to-face semi-structured in-depth interviews and analyzed according to conventional content analysis. RESULTS Data analysis identified twenty subcategories and four main categories. Main categories included barriers were related to laboring women, persons providing care, the organization environment and health system. CONCLUSIONS The adoption of evidence based intrapartum care is a complex process. In this regard, identifying potential barriers is the first step to determine and apply effective strategies to encourage the compliance evidence based obstetric care and improves maternity care quality.
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Affiliation(s)
- Mina Iravani
- Department of Midwifery, Reproductive Health Promotion Research Center, Faculty of Nursing and Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran
| | - Mohsen Janghorbani
- Department of Epidemiology, School of Health, Isfahan University of Medical Sciences, Isfahan, IR Iran
| | - Ellahe Zarean
- Department of Obstetrics and Gynecology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, IR Iran
| | - Masod Bahrami
- Department of Adult Health Nursing, Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, IR Iran
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16
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Brocklehurst P. A study of an intelligent system to support decision making in the management of labour using the cardiotocograph - the INFANT study protocol. BMC Pregnancy Childbirth 2016; 16:10. [PMID: 26791569 PMCID: PMC4719576 DOI: 10.1186/s12884-015-0780-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 12/08/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Continuous electronic fetal heart rate monitoring in labour is widely used but its potential for improving fetal and neonatal outcomes has not been realised. The most likely reason is the difficulty of interpreting the fetal heart rate trace correctly during labour. Computerised interpretation of the fetal heart rate and intelligent decision-support has the potential to deliver this improvement in care. This trial will test whether the addition of decision support software to aid the interpretation of the cardiotocogram (CTG) during labour will reduce the number of 'poor neonatal outcomes' in those women judged to require continuous electronic fetal heart rate monitoring. METHODS AND DESIGN An individually randomised controlled trial of 46,000 women who are judged to require continuous electronic fetal monitoring in labour. ELIGIBILITY CRITERIA Women admitted to a participating labour ward who are judged to require continuous electronic fetal monitoring, have a singleton or twin pregnancy, are ≥ 35 weeks' gestation, have no known gross fetal abnormality and are ≥ 16 years of age. EXCLUSION CRITERIA Triplets or higher order pregnancy, elective caesarean section prior to the onset of labour, planned admission to NICU. Trial interventions: Computerised interpretation of the CTG with decision-support. PRIMARY OUTCOMES Short term: A composite of 'poor neonatal outcome' including stillbirth after trial entry, early neonatal death except deaths due to congenital anomalies, significant morbidity: neonatal encephalopathy, admissions to the neonatal unit with 48 h for > 48 h with evidence of feeding difficulties, respiratory illness or encephalopathy where there is evidence of compromise at birth. Long term: Developmental assessment at the age of 2 years in a subset of 7000 surviving babies. DATA COLLECTION For all participating women and babies, labour variables and outcomes will be stored automatically and contemporaneously onto the Guardian® system. DISCUSSION The results of this trial will have importance for pregnant women and for health professionals who provide care for them. TRIAL REGISTRATION Current Controlled Trials ISRCTN98680152 assigned 30.09.2008.
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Affiliation(s)
- Peter Brocklehurst
- UCL EGA Institute for Women's Health, 74 Huntley Street, WC1E 6 AU, London, UK.
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17
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Hofmeyr GJ, Singata M, Lawrie T, Vogel JP, Landoulsi S, Seuc AH, Gülmezoglu AM. A multicentre randomized controlled trial of gentle assisted pushing in the upright posture (GAP) or upright posture alone compared with routine practice to reduce prolonged second stage of labour (the Gentle Assisted Pushing study): study protocol. Reprod Health 2015; 12:114. [PMID: 26669766 PMCID: PMC4681100 DOI: 10.1186/s12978-015-0105-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 12/04/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Fundal pressure (pushing on the upper part of the uterus in the direction of the birth canal) is often performed in routine practice, however the benefit and indications for its use are unclear and vigorous pressure is potentially harmful. There is some evidence that it may be applied routinely or to expedite delivery in some situations (e.g. fetal distress or maternal exhaustion), particularly in settings where other methods of achieving delivery (forceps, vacuum) are not available. Gentle assisted pushing (GAP) is an innovative method of applying gentle but steady pressure to the uterine fundus with the woman in an upright posture. This trial aims to evaluate the use of GAP in an upright posture, or upright posture alone, on reducing the mean time of delivery and the associated maternal and neonatal complications in women not having delivered following 15-30 min in the second stage of labour. METHODS/DESIGN We will conduct a multicentre, randomized, unblinded, controlled trial with three parallel arms (1:1:1). 1,145 women will be randomized at three hospitals in South Africa. Women will be eligible for inclusion if they are ≥18 years old, nulliparous, gestational age ≥ 35 weeks, have a singleton pregnancy in cephalic presentation and vaginal delivery anticipated. Women with chronic medical conditions or obstetric complications are not eligible. If eligible women are undelivered following 15-30 min in the second stage of labour, they will be randomly assigned to: 1) GAP in the upright posture, 2) upright posture only and 3) routine practice (recumbent/supine posture). The primary outcome is the mean time from randomization to complete delivery. Secondary outcomes include operative delivery, adverse neonatal outcomes, maternal adverse events and discomfort. DISCUSSION This trial will establish whether upright posture and/or a controlled method of applying fundal pressure (GAP) can improve labour outcomes for women and their babies. If fundal pressure is found to have a measurable beneficial effect, this gentle approach can be promoted as a replacement for the uncontrolled methods currently in use. If it is not found to be useful, fundal pressure can be discouraged.
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Affiliation(s)
- G Justus Hofmeyr
- Department of Obstetrics and Gynaecology at East London Hospital Complex (ELHC), Effective Care Research Unit (ECRU), and Eastern Cape Department of Health, University of the Witwatersrand, University of Fort Hare, East London, South Africa.
| | - Mandisa Singata
- Department of Obstetrics and Gynaecology at East London Hospital Complex (ELHC), Effective Care Research Unit (ECRU), and Eastern Cape Department of Health, University of the Witwatersrand, University of Fort Hare, East London, South Africa.
| | - Theresa Lawrie
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, Switzerland.
| | - Joshua P Vogel
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, Switzerland.
| | - Sihem Landoulsi
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, Switzerland.
| | - Armando H Seuc
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, Switzerland.
| | - A Metin Gülmezoglu
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, Switzerland.
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18
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Piccoli GB, Attini R, Vigotti FN, Parisi S, Fassio F, Pagano A, Biolcati M, Giuffrida D, Rolfo A, Todros T. Is renal hyperfiltration protective in chronic kidney disease-stage 1 pregnancies? A step forward unravelling the mystery of the effect of stage 1 chronic kidney disease on pregnancy outcomes. Nephrology (Carlton) 2015; 20:201-8. [PMID: 25470206 DOI: 10.1111/nep.12372] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND The correlation between advanced or proteinuric chronic kidney disease (CKD) and adverse pregnancy outcomes is intuitive, although how early CKD affects pregnancy remains unknown. Glomerular hyperfiltration is a physiological response to pregnancy, correlated with outcomes in hypertension or collagen diseases. The aim of the study was to correlate first trimester hyperfiltration with pregnancy outcomes in stage 1 CKD patients. METHODS A historical prospective study was conducted on the database of our Unit, gathering all pregnant CKD patients referred since 1 January 2000. From 383 pregnancies referred in 2000-2013, 75 patients were selected (stage 1 CKD, referred within the 14th gestational week, singleton deliveries, absence of diabetes, hypertension or nephrotic proteinuria at referral, body mass index [BMI] < 30); 267 'low-risk' pregnancies, followed in the same setting, served as controls. Glomerular filtration rate (GFR) was assessed by Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and dichotomized at 120 mL/min. The odds for Caesarean section, prematurity, need for Neonatal Intensive Care Unit (NICU) were assessed by univariate analysis and logistic regression. RESULTS Risk for adverse pregnancy outcomes was not affected by hyperfiltration (univariate OR GFR ≥ 120 mL/min: Caesarean section 1.30 (0.46-3.65); preterm delivery: 0.84 (0.25-2.80)). In contrast, even in these cases with normal kidney function, stage 1 CKD was associated with prematurity (17.3% vs 4.9% P = 0.001), lower birth weight (3027 ± 586 versus 3268 ± 500 P < 0.001) need for NICU (12% vs 1.1% P < 0.001). In the multivariate analysis, the risks were significantly increased by proteinuria and maternal age but not by GFR. CONCLUSIONS In pregnant Stage 1 CKD patients, hyperfiltration was not associated with maternal-foetal outcomes, thus suggesting a need to focus attention on qualitative factors, eventually enhanced by age, as vascular stiffness, endothelial damage or oxidative stress.
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Affiliation(s)
- Giorgina Barbara Piccoli
- SS Nefrologia, Department of Clinical and Biological Sciences, ASOU San Luigi Gonzaga, University of Turin, Turin, Italy
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Ray AF, Peirce SC, Wilkes AR, Carolan-Rees G. Vision Amniotic Leak Detector (ALD) to Eliminate Amniotic Fluid Leakage as a Cause of Vaginal Wetness in Pregnancy: A NICE Medical Technology Guidance. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2015; 13:445-56. [PMID: 26293388 PMCID: PMC4575365 DOI: 10.1007/s40258-015-0190-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
In prelabour rupture of membranes (PROM) or preterm PROM the amniotic membranes rupture prior to labour. Where this is not overt a speculum examination is undertaken to confirm diagnosis. The Vision Amniotic Leak Detector (ALD) is a panty liner that can diagnose amniotic fluid as a cause of vaginal wetness. It was evaluated by the UK National Institute for Health and Care Excellence (NICE) as part of the Medical Technologies Evaluation Programme. The sponsor (CommonSense Ltd) identified five studies, of which three were deemed within scope by the External Assessment Centre (EAC). Two of these three used an inappropriate comparator. The EAC recalculated the diagnostic accuracy of Vision ALD using speculum examination as the comparator: sensitivity of 97% (95% CI 93-99%), negative predictive value of 96% (95% CI 92-98%). A negative result would therefore allow patients to be discharged with confidence. In the sponsor's cost-consequence model only patients with a positive Vision ALD result would have a speculum examination, producing a cost saving of around £10 per patient. The EAC felt that some costs were unjustified and the model did not include infection outcomes or use in a community setting. The EAC revised the sponsor's model and found the results were most sensitive to clinician costs. Vision ALD was associated with savings of around £15-£25 per patient when administration in lower-cost community healthcare avoided a referral to a higher-cost secondary-care centre. NICE published guidance MTG15 in July 2013 recommending that the case for adopting Vision ALD was supported by the evidence.
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Affiliation(s)
- A F Ray
- Cedar, School of Engineering, Cardiff University, Cardiff, UK
| | - S C Peirce
- Cedar, School of Engineering, Cardiff University, Cardiff, UK.
| | - A R Wilkes
- Cedar, Cardiff and Vale University Health Board, Cardiff, UK
| | - G Carolan-Rees
- Cedar, Cardiff and Vale University Health Board, Cardiff, UK
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Abstract
OBJECTIVE To characterise maternal demographics, obstetric risk factors and neonatal outcomes associated with term category 1 caesarean sections (CS). DESIGN AND SETTING AND MAIN OUTCOME MEASURES Retrospective study of term singleton pregnancies delivering at a major tertiary unit in Brisbane, Australia. Category 1 CS were defined as one that required a decision-to-delivery time interval of <30 min when there was an immediate threat to the life of a woman or fetus. Neonatal outcomes analysed were gestation at delivery, birth weight, Apgar scores, acidosis at birth, need for resuscitation, admission to neonatal intensive care and neonatal seizures and death. RESULTS A total of 30,719 women delivering at term were included. Of these, 1179 (3.8%) women required a category 1 CS. A further 3527 women underwent non-category 1 CS. Most category 1 CS were performed for non-reassuring fetal status (65.9%, 777/1179). The indications for non-category 1 CS were for failure to progress (46.5%, 1641/3527) and non-reassuring fetal status (19%, 671/3527). Maternal age, body mass index and medical disease did not differ significantly between the two cohorts. Caucasian women were equally as likely to undergo a category 1 CS as a non-category 1 CS, while indigenous women and women of Asian ethnicity were more likely to undergo a category 1 CS. Significantly higher (p<0.001) perinatal complications were seen in the category 1 CS cohort--Apgar scores <7 at 1 min (20.4%, 241/1179 vs 10.7%, 377/3527) and 5 min (5.8%, 68/1179 vs 1.9%, 67/3527), umbilical arterial pH<7.2 (23.7%, 279/1179 vs 9.1%, 321/3527), neonatal resuscitation (59.9%, 706/1179 vs 51.8%, 1828/3527), neonatal intensive care unit admission (9.8%, 116/1179 vs 2.5%, 87/3527) and seizures (0.8%, 10/1179 vs 0.3%, 9/3527), respectively. CONCLUSIONS These results demonstrate significantly poorer outcomes associated with term category 1 CS compared with non-category 1 emergency CS.
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Affiliation(s)
- Leah Grace
- Mater Mothers’ Hospital, South Brisbane, Queensland, Australia
| | - Ristan M Greer
- Mater Research Institute—University of Queensland, South Brisbane, Queensland, Australia
| | - Sailesh Kumar
- Mater Mothers’ Hospital, South Brisbane, Queensland, Australia
- Mater Research Institute—University of Queensland, South Brisbane, Queensland, Australia
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Severe Adverse Maternal Outcomes among Women in Midwife-Led versus Obstetrician-Led Care at the Onset of Labour in the Netherlands: A Nationwide Cohort Study. PLoS One 2015; 10:e0126266. [PMID: 25961723 PMCID: PMC4427485 DOI: 10.1371/journal.pone.0126266] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 03/31/2015] [Indexed: 11/22/2022] Open
Abstract
Objective To test the hypothesis that it is possible to select a group of low risk women who can start labour in midwife-led care without having increased rates of severe adverse maternal outcomes compared to women who start labour in secondary care. Design and Methods We conducted a nationwide cohort study in the Netherlands, using data from 223 739 women with a singleton pregnancy between 37 and 42 weeks gestation without a previous caesarean section, with spontaneous onset of labour and a child in cephalic presentation. Information on all cases of severe acute maternal morbidity collected by the national study into ethnic determinants of maternal morbidity in the Netherlands (LEMMoN study), 1 August 2004 to 1 August 2006, was merged with data from the Netherlands Perinatal Registry of all births occurring during the same period. Our primary outcome was severe acute maternal morbidity (SAMM, i.e. admission to an intensive care unit, uterine rupture, eclampsia or severe HELLP, major obstetric haemorrhage, and other serious events). Secondary outcomes were postpartum haemorrhage and manual removal of placenta. Results Nulliparous and parous women who started labour in midwife-led care had lower rates of SAMM, postpartum haemorrhage and manual removal of placenta compared to women who started labour in secondary care. For SAMM the adjusted odds ratio’s and 95% confidence intervals were for nulliparous women: 0.57 (0.45 to 0.71) and for parous women 0.47 (0.36 to 0.62). Conclusions Our results suggest that it is possible to identify a group of women at low risk of obstetric complications who may benefit from midwife-led care. Women can be reassured that we found no evidence that midwife-led care at the onset of labour is unsafe for women in a maternity care system with a well developed risk selection and referral system.
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Iravani M, Janghorbani M, Zarean E, Bahrami M. An overview of systematic reviews of normal labor and delivery management. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2015; 20:293-303. [PMID: 26120327 PMCID: PMC4462052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 12/16/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite the scientific and medical advances for management of complicated health issues, the current maternity care setting has increased risks for healthy women and their babies. The aim of this study was to conduct an overview of published systematic reviews on the interventions used most commonly for management of normal labor and delivery in the first stage of labor. MATERIALS AND METHODS The online databases through March 2013, limited to systematic reviews of clinical trials were searched. An updated search was performed in April 2014. Two reviewers independently assessed data inclusion, extraction, and quality of methodology. RESULTS Twenty-three reviews (16 Cochrane, 7 non-Cochrane), relating to the most common care practices for management of normal labor and delivery in the first stage of labor, were included. Evidence does not support routine enemas, routine perineal shaving, continuous electronic fetal heart rate monitoring, routine early amniotomy, and restriction of fluids and food during labor. Evidence supports continuity of midwifery care and support, encouragement to non-supine position, and freedom in movement throughout labor. There is insufficient evidence to support routine administration of intravenous fluids and antispasmodics during labor. More evidence is needed regarding delayed admission until active labor and use of partograph. CONCLUSIONS Evidence-based maternity care emphasizes on the practices that increase safety for mother and baby. If policymakers and healthcare providers wish to promote obstetric care quality successfully, it is important that they implement evidence-based clinical practices in routine midwifery care.
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Affiliation(s)
- Mina Iravani
- Department of Midwifery and Reproductive Health, Student's Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran, Department of Midwifery, Reproductive Health Promotion Research Center, Faculty of Nursing and Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohsen Janghorbani
- Department of Epidemiology, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Elahe Zarean
- Department of Obstetrics and Gynecology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Masoud Bahrami
- Department of Adult Health Nursing, Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
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Li Y, Townend J, Rowe R, Brocklehurst P, Knight M, Linsell L, Macfarlane A, McCourt C, Newburn M, Marlow N, Pasupathy D, Redshaw M, Sandall J, Silverton L, Hollowell J. Perinatal and maternal outcomes in planned home and obstetric unit births in women at 'higher risk' of complications: secondary analysis of the Birthplace national prospective cohort study. BJOG 2015; 122:741-53. [PMID: 25603762 PMCID: PMC4409851 DOI: 10.1111/1471-0528.13283] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To explore and compare perinatal and maternal outcomes in women at 'higher risk' of complications planning home versus obstetric unit (OU) birth. DESIGN Prospective cohort study. SETTING OUs and planned home births in England. POPULATION 8180 'higher risk' women in the Birthplace cohort. METHODS We used Poisson regression to calculate relative risks adjusted for maternal characteristics. Sensitivity analyses explored possible effects of differences in risk between groups and alternative outcome measures. MAIN OUTCOME MEASURES Composite perinatal outcome measure encompassing 'intrapartum related mortality and morbidity' (intrapartum stillbirth, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus or clavicle) and neonatal admission within 48 hours for more than 48 hours. Two composite maternal outcome measures capturing intrapartum interventions/adverse maternal outcomes and straightforward birth. RESULTS The risk of 'intrapartum related mortality and morbidity' or neonatal admission for more than 48 hours was lower in planned home births than planned OU births [adjusted relative risks (RR) 0.50, 95% CI 0.31-0.81]. Adjustment for clinical risk factors did not materially affect this finding. The direction of effect was reversed for the more restricted outcome measure 'intrapartum related mortality and morbidity' (RR adjusted for parity 1.92, 95% CI 0.97-3.80). Maternal interventions were lower in planned home births. CONCLUSIONS The babies of 'higher risk' women who plan birth in an OU appear more likely to be admitted to neonatal care than those whose mothers plan birth at home, but it is unclear if this reflects a real difference in morbidity. Rates of intrapartum related morbidity and mortality did not differ statistically significantly between settings at the 5% level but a larger study would be required to rule out a clinically important difference between the groups.
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Affiliation(s)
- Y Li
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of OxfordOxford, UK
| | - J Townend
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of OxfordOxford, UK
| | - R Rowe
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of OxfordOxford, UK
| | - P Brocklehurst
- Institute for Women's Health, University College LondonLondon, UK
| | - M Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of OxfordOxford, UK
| | - L Linsell
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of OxfordOxford, UK
| | - A Macfarlane
- Centre for Maternal and Child Health Research, City University LondonLondon, UK
| | - C McCourt
- Centre for Maternal and Child Health Research, City University LondonLondon, UK
| | | | - N Marlow
- Institute for Women's Health, University College LondonLondon, UK
| | - D Pasupathy
- Division of Women's Health, King's College LondonLondon, UK
| | - M Redshaw
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of OxfordOxford, UK
| | - J Sandall
- Division of Women's Health, King's College LondonLondon, UK
| | | | - J Hollowell
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of OxfordOxford, UK
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AIKEN CE, AIKEN AR, PRENTICE A. Influence of the duration of the second stage of labor on the likelihood of obstetric anal sphincter injury. Birth 2015; 42:86-93. [PMID: 25439012 PMCID: PMC4329065 DOI: 10.1111/birt.12137] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2014] [Indexed: 01/12/2023]
Abstract
BACKGROUND Duration of the second stage of labor has been suggested as an independent risk factor for clinically detectable obstetric anal sphincter injury in low-risk nulliparous women. METHODS A retrospective 5-year cohort study was conducted in a UK obstetrics center which included a high-risk delivery unit and a low-risk birthing center. The study included 4,831 nulliparous women with vertex-presenting, single, live-born infants at term, stratified according to spontaneous or instrumental delivery. Binary logistic regression models were used to examine the association between duration of second stage and sphincter injury. RESULTS Three-hundred twenty-five of 4,831 women (6.7%) sustained sphincter injuries. In spontaneously delivering women, no association between duration of the second stage and the likelihood of sphincter injury was recorded. Factors associated with increased likelihood of sphincter injury included older maternal age, higher birthweight, and Southeast Asian ethnicity. In contrast, for women undergoing instrumental delivery, a longer second stage was associated with an increased sphincter injury risk of 6 percent per 15 minutes in the second stage of labor before delivery. CONCLUSIONS For spontaneous vaginal deliveries, duration of the second stage of labor was not an independent risk factor for obstetric anal sphincter injury. The association between prolonged second stage and sphincter injury for instrumental deliveries is likely explained by the risk posed by the use of the instruments themselves or by delay in initiating instrumental assistance. Attempts to modify the duration of the second stage for prevention of sphincter injuries are unlikely to be beneficial and may be detrimental.
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Affiliation(s)
- Catherine E. AIKEN
- Department of Obstetrics and Gynaecology, University of Cambridge; NIHR Cambridge Comprehensive Biomedical Research Centre, CB2 2SW, UK
- University of Cambridge Metabolic Research Laboratories and Medical Research Council Metabolic Diseases Unit, Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Abigail R. AIKEN
- Office of Population Research, Princeton University, Princeton, NJ, USA
| | - Andrew PRENTICE
- Department of Obstetrics and Gynaecology, University of Cambridge; NIHR Cambridge Comprehensive Biomedical Research Centre, CB2 2SW, UK
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Izuka EO, Dim CC, Chigbu CO, Obiora-Izuka CE. Prevalence and predictors of episiotomy among women at first birth in enugu, South-East Nigeria. Ann Med Health Sci Res 2014; 4:928-32. [PMID: 25506488 PMCID: PMC4250993 DOI: 10.4103/2141-9248.144916] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Women having their first birth have a higher risk of episiotomies. Therefore, the study of the procedure in this group of at risk women will assist in solving some of its associated controversies. AIM The aim was to determine the prevalence, predictors, and outcomes of episiotomy among primigravid women in Enugu, Nigeria. MATERIALS AND METHODS The study was a retrospective cross-sectional review of labor ward records of women that had their first delivery at the University of Nigeria Teaching Hospital (UNTH) Enugu, over a 5-year of April 204 to March 2009. Only women that had a vaginal delivery were included in the study. Mann-Whitney U-test (continuous data) and Chi-square test (categorical data) were used for data analysis. RESULTS Prevalence of episiotomy in the study was 62.1% (411/662). The episiotomy rate for booked women (65.6%, 376/573) was significantly higher than that of unbooked women (39.3%, 35/89), (prevalence ratio = 1.67 [95% confidence interval: 1.28, 2.17]). The birth weights of babies delivered in the episiotomy group (median = 3.2 kg [interquartile range (IQR): 2.9-3.5]) was statistically higher than those of women who did not receive episiotomy (median, 3.1 kg [IQR: 2.7-3.4]), (Z = -3.415, P = 0.001). Proportion of newborns with low 1(st) min Apgar scores in the episiotomy group (21.7%, 89/411) was significantly lower than the no episiotomy group (15.1%, 38/251) (P = 0.04). CONCLUSION Prevalence of episiotomy among women that had their first births in the UNTH, Enugu was high, and the predictors included booked status of women, higher gestational age at delivery, and larger neonatal birth weight. More efforts should be made to reduce episiotomy rate in the hospital.
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Affiliation(s)
- EO Izuka
- Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - CC Dim
- Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - CO Chigbu
- Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - CE Obiora-Izuka
- Department of Pediatrics, University of Nigeria Teaching Hospital, Enugu, Nigeria
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Oddie S, Rhodes P. Barriers to deferred cord clamping in preterm infants. Arch Dis Child Fetal Neonatal Ed 2014; 99:F391-4. [PMID: 24903454 PMCID: PMC4145419 DOI: 10.1136/archdischild-2014-305968] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 04/08/2014] [Accepted: 05/14/2014] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To describe the range of practices employed by units conducting deferred cord clamping at very preterm birth. DESIGN Qualitative study using semistructured interviews with neonatal doctors, nurses, midwives, obstetricians and managers in a sample of UK maternity units. PARTICIPANTS 33 neonatal doctors, neonatal nurses, midwives, obstetricians and managers. SETTING UK maternity units in 2012. RESULTS Four key themes emerged. The first concerns the variation in guideline content, the absence of a practice of stabilisation with cord intact, and issues with implementing and maintaining changes in practice. The second concerns the challenges in assessing eligibility. The third concerns the competing priorities of delivering the intervention and proceeding with other stabilisation manoeuvres and the associated anxiety experienced by professionals. The final theme relates to the issue of uncertainty as to optimal treatment choices. CONCLUSIONS The evidence surrounding deferred cord clamping in very preterm infants is unclear. This study describes the reported practice of units deferring cord clamping in 2012 and will inform trial development.
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Affiliation(s)
- Sam Oddie
- Department of Bradford Neonatology, Ward M1, Bradford Royal Infirmary, Bradford, UK
| | - Penny Rhodes
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
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Rowe RE, Townend J, Brocklehurst P, Knight M, Macfarlane A, McCourt C, Newburn M, Redshaw M, Sandall J, Silverton L, Hollowell J. Service configuration, unit characteristics and variation in intervention rates in a national sample of obstetric units in England: an exploratory analysis. BMJ Open 2014; 4:e005551. [PMID: 24875492 PMCID: PMC4039829 DOI: 10.1136/bmjopen-2014-005551] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 05/03/2014] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES To explore whether service configuration and obstetric unit (OU) characteristics explain variation in OU intervention rates in 'low-risk' women. DESIGN Ecological study using funnel plots to explore unit-level variations in adjusted intervention rates and simple linear regression, stratified by parity, to investigate possible associations between unit characteristics/configuration and adjusted intervention rates in planned OU births. Characteristics considered: OU size, presence of an alongside midwifery unit (AMU), proportion of births in the National Health Service (NHS) trust planned in midwifery units or at home and midwifery 'under' staffing. SETTING 36 OUs in England. PARTICIPANTS 'Low-risk' women with a 'term' pregnancy planning vaginal birth in a stratified, random sample of 36 OUs. MAIN OUTCOME MEASURES Adjusted rates of intrapartum caesarean section, instrumental delivery and two composite measures capturing birth without intervention ('straightforward' and 'normal' birth). RESULTS Funnel plots showed unexplained variation in adjusted intervention rates. In NHS trusts where proportionately more non-OU births were planned, adjusted intrapartum caesarean section rates in the planned OU births were significantly higher (nulliparous: R(2)=31.8%, coefficient=0.31, p=0.02; multiparous: R(2)=43.2%, coefficient=0.23, p=0.01), and for multiparous women, rates of 'straightforward' (R(2)=26.3%, coefficient=-0.22, p=0.01) and 'normal' birth (R(2)=17.5%, coefficient=0.24, p=0.01) were lower. The size of the OU (number of births), midwifery 'under' staffing levels (the proportion of shifts where there were more women than midwives) and the presence of an AMU were associated with significant variation in some interventions. CONCLUSIONS Trusts with greater provision of non-OU intrapartum care may have higher intervention rates in planned 'low-risk' OU births, but at a trust level this is likely to be more than offset by lower intervention rates in planned non-OU births. Further research using high quality data on unit characteristics and outcomes in a larger sample of OUs and trusts is required.
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Affiliation(s)
- Rachel E Rowe
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - John Townend
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Peter Brocklehurst
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Institute for Women's Health, University College London, London, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alison Macfarlane
- Centre for Maternal and Child Health Research, City University London, London, UK
| | - Christine McCourt
- Centre for Maternal and Child Health Research, City University London, London, UK
| | | | - Maggie Redshaw
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jane Sandall
- Division of Women's Health, King's College London, London, UK
| | | | - Jennifer Hollowell
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Prosser SJ, Miller YD, Thompson R, Redshaw M. Why 'down under' is a cut above: a comparison of rates of and reasons for caesarean section in England and Australia. BMC Pregnancy Childbirth 2014; 14:149. [PMID: 24767675 PMCID: PMC4021562 DOI: 10.1186/1471-2393-14-149] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 04/22/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Most studies examining determinants of rising rates of caesarean section have examined patterns in documented reasons for caesarean over time in a single location. Further insights could be gleaned from cross-cultural research that examines practice patterns in locations with disparate rates of caesarean section at a single time point. METHODS We compared both rates of and main reason for pre-labour and intrapartum caesarean between England and Queensland, Australia, using data from retrospective cross-sectional surveys of women who had recently given birth in England (n = 5,250) and Queensland (n = 3,467). RESULTS Women in Queensland were more likely to have had a caesarean birth (36.2%) than women in England (25.1% of births; OR = 1.44, 95% CI = 1.28-1.61), after adjustment for obstetric characteristics. Between-country differences were found for rates of pre-labour caesarean (21.2% vs. 12.2%) but not for intrapartum caesarean or assisted vaginal birth. Compared to women in England, women in Queensland with a history of caesarean were more likely to have had a pre-labour caesarean and more likely to have had an intrapartum caesarean, due only to a previous caesarean. Among women with no previous caesarean, Queensland women were more likely than women in England to have had a caesarean due to suspected disproportion and failure to progress in labour. CONCLUSIONS The higher rates of caesarean birth in Queensland are largely attributable to higher rates of caesarean for women with a previous caesarean, and for the main reason of having had a previous caesarean. Variation between countries may be accounted for by the absence of a single, comprehensive clinical guideline for caesarean section in Queensland.
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Affiliation(s)
| | - Yvette D Miller
- School of Psychology, The University of Queensland, Brisbane, Australia
- School of Public Health & Social Work, Queensland University of Technology, Brisbane, Australia
| | - Rachel Thompson
- School of Psychology, The University of Queensland, Brisbane, Australia
- The Dartmouth Center for Health Care Delivery Science, Dartmouth College, Hanover, NH, USA
| | - Maggie Redshaw
- School of Psychology, The University of Queensland, Brisbane, Australia
- Policy Research Unit for Maternal Health and Care, National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
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Abou El Senoun G, Dowswell T, Mousa HA. Planned home versus hospital care for preterm prelabour rupture of the membranes (PPROM) prior to 37 weeks' gestation. Cochrane Database Syst Rev 2014; 2014:CD008053. [PMID: 24729384 PMCID: PMC11008104 DOI: 10.1002/14651858.cd008053.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Preterm prelabour rupture of membranes (PPROM) is associated with increased risk of maternal and neonatal morbidity and mortality. Women with PPROM have been predominantly managed in hospital. It is possible that selected women could be managed at home after a period of observation. The safety, cost and women's views about home management have not been established. OBJECTIVES To assess the safety, cost and women's views about planned home versus hospital care for women with PPROM. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2013) and the reference lists of all the identified articles. SELECTION CRITERIA Randomised and quasi-randomised trials comparing planned home versus hospital management for women with PPROM before 37 weeks' gestation. DATA COLLECTION AND ANALYSIS Two review authors independently assessed clinical trials for eligibility for inclusion, risk of bias, and carried out data extraction. MAIN RESULTS We included two trials (116 women) comparing planned home versus hospital management for PPROM. Overall, the number of included women in each trial was too small to allow adequate assessment of pre-specified outcomes. Investigators used strict inclusion criteria and in both studies relatively few of the women presenting with PPROM were eligible for inclusion. Women were monitored for 48 to 72 hours before randomisation. Perinatal mortality was reported in one trial and there was insufficient evidence to determine whether it differed between the two groups (risk ratio (RR) 1.93, 95% confidence interval (CI) 0.19 to 20.05). There was no evidence of differences between groups for serious neonatal morbidity, chorioamnionitis, gestational age at delivery, birthweight and admission to neonatal intensive care.There was no information on serious maternal morbidity or mortality. There was some evidence that women managed in hospital were more likely to be delivered by caesarean section (RR (random-effects) 0.28, 95% CI 0.07 to 1.15). However, results should be interpreted cautiously as there is moderate heterogeneity for this outcome (I² = 35%). Mothers randomised to care at home spent approximately 10 fewer days as inpatients (mean difference -9.60, 95% CI -14.59 to -4.61) and were more satisfied with their care. Furthermore, home care was associated with reduced costs. AUTHORS' CONCLUSIONS The review included two relatively small studies that did not have sufficient statistical power to detect meaningful differences between groups. Future large and adequately powered randomised controlled trials are required to measure differences between groups for relevant pre-specified outcomes. Special attention should be given to the assessment of maternal satisfaction with care and cost analysis as they will have social and economic implications in both developed and developing countries.
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Affiliation(s)
- Ghada Abou El Senoun
- Queen's Medical Centre, Nottingham University HospitalDepartment of Obstetrics and GynaecologyDerby RoadNottinghamNottinghamshireUKNG7 2UH
| | - Therese Dowswell
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Hatem A Mousa
- Leicester Royal InfirmaryUniversity Department of Obstetrics and Gynaecology, Fetal and Maternal Medicine UnitInfirmary SquareLeicesterUKLE1 5WW
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Phipps H, de Vries B, Jagadish U, Hyett J. Management of occiput posterior position in the second stage of labor: a survey of midwifery practice in Australia. Birth 2014; 41:64-9. [PMID: 24654638 DOI: 10.1111/birt.12094] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/29/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND The management of the occiput posterior (OP) position has been controversial for many years. Manual rotation can be performed by midwives and could reduce cesarean sections and instrumental births. We aimed to determine current midwifery views, knowledge, and practice of manual rotation. METHOD A de-identified, self-reported questionnaire was e-mailed to all Australian College of Midwives full members (n = 3,997). RESULTS Of 3,182 surveyed, 57 percent (1,817) responded, of whom 51 percent (920) were currently practicing midwifery. Seventy-seven percent of midwives thought that manual rotation at full dilatation was a valid intervention. Sixty-four percent stated the procedure was acceptable before instrumental delivery, but 30 percent were unsure. Most practicing midwives (93%) had heard of manual rotation, but only 18 percent had performed one in the last year. Midwives would support the routine performance of manual rotation for OP position if it reduced operative births from 68 to 50 percent and would support manual rotation for occiput transverse (OT) position if it reduced operative births from 39 to 25 percent. CONCLUSION This study indicates that manual rotation is considered acceptable by most midwives in Australia, yet is only performed by a minority. Midwives would be willing to perform prophylactic manual rotation if it was known to facilitate normal vaginal births suggesting a scope to introduce this procedure into widespread clinical practice.
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Affiliation(s)
- Hala Phipps
- RPA Women and Babies, Royal Prince Alfred Hospital, Sydney, Australia; Discipline of Obstetrics, Gynaecology and Neonatology, Faculty of Medicine, University of Sydney, Sydney, Australia; Faculty of Nursing and Midwifery, University of Sydney, Sydney, Australia
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Lukasse M, Rowe R, Townend J, Knight M, Hollowell J. Immersion in water for pain relief and the risk of intrapartum transfer among low risk nulliparous women: secondary analysis of the Birthplace national prospective cohort study. BMC Pregnancy Childbirth 2014; 14:60. [PMID: 24499396 PMCID: PMC3922427 DOI: 10.1186/1471-2393-14-60] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 02/04/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Immersion in water during labour is an important non-pharmacological method to manage labour pain, particularly in midwifery-led care settings where pharmacological methods are limited. This study investigates the association between immersion for pain relief and transfer before birth and other maternal outcomes. METHODS A prospective cohort study of 16,577 low risk nulliparous women planning birth at home, in a freestanding midwifery unit (FMU) or in an alongside midwifery unit (AMU) in England between April 2008 and April 2010. RESULTS Immersion in water for pain relief was common; 50% in planned home births, 54% in FMUs and 38% in AMUs. Immersion in water was associated with a lower risk of transfer before birth for births planned at home (adjusted RR 0.88; 95% CI 0.79-0.99), in FMUs (adjusted RR 0.59; 95% CI 0.50-0.70) and in AMUs (adjusted RR 0.78; 95% CI 0.69-0.88). For births planned in FMUs, immersion in water was associated with a lower risk of intrapartum caesarean section (RR 0.61; 95% CI 0.44-0.84) and a higher chance of a straightforward vaginal birth (RR 1.09; 95% CI 1.04-1.15). These beneficial effects were not seen in births planned at home or AMUs. CONCLUSIONS Immersion of water for pain relief was associated with a significant reduction in risk of transfer before birth for nulliparous women. Overall, immersion in water was associated with fewer interventions during labour. The effect varied across birth settings with least effect in planned home births and a larger effect observed for planned FMU births.
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Affiliation(s)
- Mirjam Lukasse
- Department of Public Health and General Practice at the Faculty of Medicine, The Norwegian University of Science and Technology (NTNU), Håkon Jarls gate 11, N-7489 Trondheim, Norway
- Department of Health, Nutrition and Management, Faculty of Health Sciences, Oslo and Akershus University College of Applied Sciences, Postboks 364 Alnabru, N-0614 Oslo, Norway
| | - Rachel Rowe
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford OX3 7LF, England
| | - John Townend
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford OX3 7LF, England
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford OX3 7LF, England
| | - Jennifer Hollowell
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford OX3 7LF, England
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Rajab SS, Alalaf SK. Umbilical vein injection of misoprostol versus normal saline for the treatment of retained placenta: intrapartum placebo-controlled trial. BMC Pregnancy Childbirth 2014; 14:37. [PMID: 24444360 PMCID: PMC3900733 DOI: 10.1186/1471-2393-14-37] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 01/16/2014] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The third stage of labour may be complicated by retained placenta, which should be managed promptly because it may cause severe bleeding and infection, with a potentially fatal outcome. This study evaluated the effectiveness of umbilical vein injection of misoprostol for the treatment of retained placenta in a hospital setting. METHODS This hospital-based placebo-controlled trial was conducted at the Maternity Teaching Hospital, Erbil City, Kurdistan region, Northern Iraq from April 2011 to February 2012. The inclusion criteria were: gestational age of at least 28 weeks, vaginal delivery, and failure of the placenta to separate within 30 minutes after delivery of the infant despite active management of the third stage of labour. Forty-six women with retained placentas were eligible for inclusion. After informed consent was obtained, the women were alternately allocated to receive umbilical vein injection of either 800 mcg misoprostol dissolved in 20 mL of normal saline (misoprostol group) or 20 mL of normal saline only (saline group). The women were blinded to the group allocation, but the investigator who administered the injection was not. The trial was registered by the Research Ethics Committee of Hawler Medical University. RESULTS After umbilical vein injection, delivery of the placenta occurred in 91.3% of women in the misoprostol group and 69.5% of women in the saline group, which was not a significant difference between the two groups. The median vaginal blood loss from the time of injection until delivery of the placenta was significantly less in the misoprostol group (100 mL) than in the saline group (210 mL) (p value < 0.001). CONCLUSION Umbilical vein injection of misoprostol is an effective treatment for retained placenta, and reduces the volume of vaginal blood loss with few adverse effects. CLINICAL TRIAL REGISTRATION Current Controlled Trial HMU: N252.1.2011.
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Affiliation(s)
- Sheelan S Rajab
- Department of Obstetrics and Gynaecology, Shaheed Dr.Khalid General Hospital, Erbil City, Iraq
| | - Shahla K Alalaf
- Department of Obstetrics and Gynaecology, College of Medicine, Hawler Medical University, Erbil City, Iraq
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Osaikhuwuomwan JA, Osemwenkha AP. Maternal characteristics and timing of presentation following pre-labour rupture of membranes. Niger Med J 2014; 55:58-62. [PMID: 24970972 PMCID: PMC4071665 DOI: 10.4103/0300-1652.128169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND To examine the influence of maternal characteristics on timing of presentation for intervention following pre-labour rupture of membrane (PROM) at term. MATERIALS AND METHODS This was a descriptive study of cases of term PROM with singleton births at the University of Benin Teaching Hospital (UBTH) from October 2011 to December 2012. Interval from onset of PROM to presentation to hospital was used as dependent variable. From the study population, two groups were identified based on time interval (≤24 hours or >24 hours) from PROM to presentation to hospital and their relationship to socio-demographic characteristic examined. RESULTS Over the study period, records of 110 women met the inclusion criteria and were selected for analysis. Their mean age was 29.26 ± 0.67 years; they were all married with 41.8% being nulliparous women. The mean gestational age at presentation with PROM was 38.5 ± 1.2. Over 50% had tertiary level of education. Overall, 38.2% were in social class 1. With regard to maternal response behaviour to PROM, 65.5% presented to the hospital within 24 hours while 34.5% presented after 24 hours of rupture of membranes. Majority of those that presented within 24 hours of PROM were in (upper) social class 1 and 2 and this differed significantly from those that presented after 24 hours, most of whom were in (lower) social class 3,4 and 5; [56 (77.8%) vs 16 (22.2%) and 14 (36.8%) vs 24 (63.2%)] P = 0.0001. CONCLUSION Delay in presentation after PROM, illustrative of maternal under utilisation of BPACR package, is associated with being in a lower social class. Socio-economic and educational empowerment of women is advocated, while prospective research on maternal perception and attitude towards ANC is proposed.
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Affiliation(s)
- James A. Osaikhuwuomwan
- Department of Obstetrics and Gynaecology, College of Medical Sciences, University of Benin, Benin, Nigeria
| | - Abieyuwa P. Osemwenkha
- Department of Obstetrics and Gynaecology, College of Medical Sciences, University of Benin, Benin, Nigeria
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Rowe RE, Townend J, Brocklehurst P, Knight M, Macfarlane A, McCourt C, Newburn M, Redshaw M, Sandall J, Silverton L, Hollowell J. Duration and urgency of transfer in births planned at home and in freestanding midwifery units in England: secondary analysis of the birthplace national prospective cohort study. BMC Pregnancy Childbirth 2013; 13:224. [PMID: 24314134 PMCID: PMC4029797 DOI: 10.1186/1471-2393-13-224] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 11/27/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In England, there is a policy of offering healthy women with straightforward pregnancies a choice of birth setting. Options may include home or a freestanding midwifery unit (FMU). Transfer rates from these settings are around 20%, and higher for nulliparous women. The duration of transfer is of interest because of the potential for delay in access to specialist care and is also of concern to women. We aimed to estimate the duration of transfer in births planned at home and in FMUs and explore the effects of distance and urgency on duration. METHODS This was a secondary analysis of data collected in a national prospective cohort study including 27,842 'low risk' women with singleton, term, 'booked' pregnancies, planning birth in FMUs or at home in England from April 2008 to April 2010. We described transfer duration using the median and interquartile range, for all transfers and those for reasons defined as potentially urgent or non-urgent, and used cumulative distribution curves to compare transfer duration by urgency. We explored the effect of distance for transfers from FMUs and described outcomes in women giving birth within 60 minutes of transfer. RESULTS The median overall transfer time, from decision to transfer to first OU assessment, was shorter in transfers from home compared with transfers from FMUs (49 vs 60 minutes; p < 0.001). The median duration of transfers before birth for potentially urgent reasons (home 42 minutes, FMU 50 minutes) was 8-10 minutes shorter compared with transfers for non-urgent reasons. In transfers for potentially urgent reasons, the median overall transfer time from FMUs within 20 km of an OU was 47 minutes, increasing to 55 minutes from FMUs 20-40 km away and 61 minutes in more remote FMUs. In women who gave birth within 60 minutes after transfer, adverse neonatal outcomes occurred in 1-2% of transfers. CONCLUSIONS Transfers from home or FMU commonly take up to 60 minutes from decision to transfer, to first assessment in an OU, even for transfers for potentially urgent reasons. Most transfers are not urgent and emergencies and adverse outcomes are uncommon, but urgent transfer is more likely for nulliparous women.
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Affiliation(s)
- Rachel E Rowe
- National Perinatal Epidemiology Unit, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
| | - John Townend
- National Perinatal Epidemiology Unit, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
| | - Peter Brocklehurst
- National Perinatal Epidemiology Unit, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
- Institute for Women’s Health, University College London, London, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
| | - Alison Macfarlane
- Department of Midwifery and Child Health, City University London, London, UK
| | - Christine McCourt
- Department of Midwifery and Child Health, City University London, London, UK
| | | | - Maggie Redshaw
- National Perinatal Epidemiology Unit, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
| | - Jane Sandall
- Division of Women’s Health, King’s College London, London, UK
| | | | - Jennifer Hollowell
- National Perinatal Epidemiology Unit, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
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Law GR, Cattle B, Farrar D, Scott EM, Gilthorpe MS. Placental blood transfusion in newborn babies reaches a plateau after 140 s: Further analysis of longitudinal survey of weight change. SAGE Open Med 2013; 1:2050312113503321. [PMID: 26770679 PMCID: PMC4687772 DOI: 10.1177/2050312113503321] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE With the introduction of active management of the third stage of labour in the 1960s, it became usual practice to clamp and cut the umbilical cord immediately following birth. The timing of this cord clamping is controversial, as blood may beneficially be transferred to the baby if clamping of the cord is delayed slightly. There is no agreement, however, on how long the delay should be before clamping the cord. This study aimed to establish when blood ceased to flow in the umbilical cord to determine how long to delay clamping of the umbilical cord following delivery of the term newborn to maximise placental transfusion. METHODS This observational study collected longitudinal weight measurements set in a hospital labour ward. A total of 26 mothers at term and their singleton babies participated in the study. In this reanalysis, the velocity of weight change over the first minutes of life determined by functional data analysis was estimated. RESULTS We found that the flow velocity in the umbilical cord was on average 0 at 125 s after placing the baby on the scales, which was typically 140 s after birth. CONCLUSIONS To maximise placental transfusion, cord clamping should be delayed for at least 140 s following birth of the baby.
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Affiliation(s)
- Graham R Law
- Division of Biostatistics, Centre for Epidemiology and Biostatistics, University of Leeds, Leeds, UK
| | - Brian Cattle
- Division of Biostatistics, Centre for Epidemiology and Biostatistics, University of Leeds, Leeds, UK
| | - Diane Farrar
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
| | - Eleanor M Scott
- Division of Diabetes and Cardiovascular Research, Centre for Epidemiology and Biostatistics, University of Leeds, Leeds, UK
| | - Mark S Gilthorpe
- Division of Biostatistics, Centre for Epidemiology and Biostatistics, University of Leeds, Leeds, UK
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Lippert T, Nesje E, Koss KS, Oian P. Change in risk status during labor in a large Norwegian obstetric department: a prospective study. Acta Obstet Gynecol Scand 2013; 92:671-8. [PMID: 23362836 DOI: 10.1111/aogs.12092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 01/08/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This study aimed to observe risk status on admission to hospital and change in risk status during labor. DESIGN A prospective observational study allocating all women into low-risk and high-risk groups on admittance to hospital and during labor based on prespecified risk criteria. SETTING Department of Obstetrics and Gynecology in a district hospital. POPULATION All 6406 deliveries from 2 May 2004 to 30 September 2006. METHODS A special form was filled out for all women admitted to the department in labor classifying them as either low or high risk. A change in risk status during labor was also recorded. MAIN OUTCOME MEASURES Risk status (low and high risk) on admittance to hospital and change in risk status during first stage of labor. RESULTS On admittance, 67% of women with an intended vaginal delivery were low risk. During the first stage of labor, 41% of the low-risk women changed risk status. Use of epidural anesthesia gave rise to 73% of the risk changes during the first stage of labor and use of oxytocin caused 12%. CONCLUSIONS Two-thirds of the women were low risk before labor, and 39% of these remained low-risk at the end of the first stage of labor. The main reason for a change of risk status in the obstetric department was the use of epidural anesthesia.
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Affiliation(s)
- Tonje Lippert
- Department of Obstetrics and Gynecology, Baerum Hospital, Baerum, Norway.
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Abstract
The dominant culture in labor and birth is the medical model, not the midwifery model of woman-centered care. Consensus among professional and governmental groups is that, based on the evidence, intermittent auscultation is safer to use in healthy women with uncomplicated pregnancies than electronic fetal monitoring (EFM). Barriers impact the laboring woman's ability to give informed choice regarding fetal monitoring. Lack of informed choice denies a woman her right to be in control of her birth experience, and is in opposition to a woman's right to autonomy and self-determination.
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Lee D, Johnson J. Hysterotomy for retained placenta in a septate uterus: a case report. Case Rep Obstet Gynecol 2012; 2012:594140. [PMID: 22720179 PMCID: PMC3375073 DOI: 10.1155/2012/594140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2012] [Accepted: 04/22/2012] [Indexed: 11/26/2022] Open
Abstract
Retained placenta is a common complication of the third stage of labor. Most literature has focused on management of a trapped placenta or placenta accreta. The most common source of a trapped placenta is from a partial closure of the cervix and/or a contracted lower uterine segment. We present an unusual case of a retained placenta trapped in a septate uterus. The management included unsuccessful conservative measures that resulted in delivery of the placenta by laparotomy with hysterotomy.
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Affiliation(s)
- Daniel Lee
- Department of Obestrics and Gynecology, Oklahoma State University, 717 S. Houston Avenue, Suite 200, Tulsa, OK 74127, USA
| | - Joseph Johnson
- Department of Obestrics and Gynecology, Oklahoma State University, 717 S. Houston Avenue, Suite 200, Tulsa, OK 74127, USA
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Schroeder E, Petrou S, Patel N, Hollowell J, Puddicombe D, Redshaw M, Brocklehurst P. Cost effectiveness of alternative planned places of birth in woman at low risk of complications: evidence from the Birthplace in England national prospective cohort study. BMJ 2012; 344:e2292. [PMID: 22517916 PMCID: PMC3330132 DOI: 10.1136/bmj.e2292] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2012] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To estimate the cost effectiveness of alternative planned places of birth. DESIGN Economic evaluation with individual level data from the Birthplace national prospective cohort study. SETTING 142 of 147 trusts providing home birth services, 53 of 56 freestanding midwifery units, 43 of 51 alongside midwifery units, and a random sample of 36 of 180 obstetric units, stratified by unit size and geographical region, in England, over varying periods of time within the study period 1 April 2008 to 30 April 2010. PARTICIPANTS 64,538 women at low risk of complications before the onset of labour. INTERVENTIONS Planned birth in four alternative settings: at home, in freestanding midwifery units, in alongside midwifery units, and in obstetric units. MAIN OUTCOME MEASURES Incremental cost per adverse perinatal outcome avoided, adverse maternal morbidity avoided, and additional normal birth. The non-parametric bootstrap method was used to generate net monetary benefits and construct cost effectiveness acceptability curves at alternative thresholds for cost effectiveness. RESULTS The total unadjusted mean costs were £1066, £1435, £1461, and £1631 for births planned at home, in freestanding midwifery units, in alongside midwifery units, and in obstetric units, respectively (equivalent to about €1274, $1701; €1715, $2290; €1747, $2332; and €1950, $2603). Overall, and for multiparous women, planned birth at home generated the greatest mean net benefit with a 100% probability of being the optimal setting across all thresholds of cost effectiveness when perinatal outcomes were considered. There was, however, an increased incidence of adverse perinatal outcome associated with planned birth at home in nulliparous low risk women, resulting in the probability of it being the most cost effective option at a cost effectiveness threshold of £20 000 declining to 0.63. With regards to maternal outcomes in nulliparous and multiparous women, planned birth at home generated the greatest mean net benefit with a 100% probability of being the optimal setting across all thresholds of cost effectiveness. CONCLUSIONS For multiparous women at low risk of complications, planned birth at home was the most cost effective option. For nulliparous low risk women, planned birth at home is still likely to be the most cost effective option but is associated with an increase in adverse perinatal outcomes.
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Affiliation(s)
- Elizabeth Schroeder
- National Perinatal Epidemiology Unit, Department of Public Health, University of Oxford, Oxford OX3 7LF, UK.
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Bernitz S, Rolland R, Blix E, Jacobsen M, Sjøborg K, Øian P. Is the operative delivery rate in low-risk women dependent on the level of birth care? A randomised controlled trial. BJOG 2011; 118:1357-64. [PMID: 21749629 PMCID: PMC3187863 DOI: 10.1111/j.1471-0528.2011.03043.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Objective To investigate possible differences in operative delivery rate among low-risk women, randomised to an alongside midwifery-led unit or to standard obstetric units within the same hospital. Design Randomised controlled trial. Setting Department of Obstetrics and Gynaecology, Østfold Hospital Trust, Tromsø, Norway. Population A total of 1111 women assessed to be at low risk at onset of spontaneous labour. Methods Randomisation into one of three birth units: the special unit; the normal unit; or the midwife-led unit. Main outcome measures Total operative delivery rate, augmentation, pain relief, postpartum haemorrhage, sphincter injuries and intrapartum transfer, Apgar score <7 at 5 minutes, metabolic acidosis and transfer to neonatal intensive care unit. Results There were no significant differences in total operative deliveries between the three units: 16.3% in the midwife-led unit; 18.0% in the normal unit; and 18.8% in the special unit. There were no significant differences in postpartum haemorrhage, sphincter injuries or in neonatal outcomes. There were statistically significant differences in augmentation (midwife-led unit versus normal unit RR 0.73, 95% CI 0.59–0.89; midwife-led unit versus special unit RR 0.69, 95% CI 0.56–0.86), in epidural analgesia (midwife-led unit versus normal unit RR 0.68, 95% CI 0.52–0.90; midwife-led unit versus special unit RR 0.64, 95% CI 0.47–0.86) and in acupuncture (midwife-led unit versus normal unit RR 1.45, 95% CI 1.25–1.69; midwife-led unit versus special unit RR 1.45, 95% CI 1.22–1.73). Conclusions The level of birth care does not significantly affect the rate of operative deliveries in low-risk women without any expressed preference for level of birth care.
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Affiliation(s)
- S Bernitz
- Department of Obstetrics and Gynaecology at Østfold Hospital Trust, Fredrikstad, Norway.
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Maso G, Alberico S, Wiesenfeld U, Ronfani L, Erenbourg A, Hadar E, Yogev Y, Hod M. "GINEXMAL RCT: Induction of labour versus expectant management in gestational diabetes pregnancies". BMC Pregnancy Childbirth 2011; 11:31. [PMID: 21507262 PMCID: PMC3108319 DOI: 10.1186/1471-2393-11-31] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Accepted: 04/20/2011] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Gestational diabetes (GDM) is one of the most common complications of pregnancies affecting around 7% of women. This clinical condition is associated with an increased risk of developing fetal macrosomia and is related to a higher incidence of caesarean section in comparison to the general population. Strong evidence indicating the best management between induction of labour at term and expectant monitoring are missing. METHODS/DESIGN Pregnant women with singleton pregnancy in vertex presentation previously diagnosed with gestational diabetes will be asked to participate in a multicenter open-label randomized controlled trial between 38+0 and 39+0 gestational weeks. Women will be recruited in the third trimester in the outpatient clinic or in the Day Assessment Unit according to local protocols. Women who opt to take part will be randomized according to induction of labour or expectant management for spontaneous delivery. Patients allocated to the induction group will be admitted to the obstetric ward and offered induction of labour via use of prostaglandins, Foley catheter or oxytocin (depending on clinical conditions). Women assigned to the expectant arm will be sent to their domicile where they will be followed up until delivery, through maternal and fetal wellbeing monitoring twice weekly. The primary study outcome is the Caesarean section (C-section) rate, whilst secondary measurements are maternal and neonatal outcomes. A total sample of 1760 women (880 each arm) will be recruited to identify a relative difference between the two arms equal to 20% in favour of induction, with concerns to C-section rate. Data will be collected until mothers and newborns discharge from the hospital. Analysis of the outcome measures will be carried out by intention to treat. DISCUSSION The present trial will provide evidence as to whether or not, in women affected by gestational diabetes, induction of labour between 38+0 and 39+0 weeks is an effective management to ameliorate maternal and neonatal outcomes. The primary objective is to determine whether caesarean section rate could be reduced among women undergoing induction of labour, in comparison to patients allocated to expectant monitoring. The secondary objective consists of the assessment and comparison of maternal and neonatal outcomes in the two study arms. .
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Affiliation(s)
- Gianpaolo Maso
- Department of Obstetrics and Gynaecology, Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Via dell'Istria 65/1 34137, Trieste, Italy
| | - Salvatore Alberico
- Department of Obstetrics and Gynaecology, Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Via dell'Istria 65/1 34137, Trieste, Italy
| | - Uri Wiesenfeld
- Department of Obstetrics and Gynaecology, Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Via dell'Istria 65/1 34137, Trieste, Italy
| | - Luca Ronfani
- Department of Obstetrics and Gynaecology, Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Via dell'Istria 65/1 34137, Trieste, Italy
| | - Anna Erenbourg
- Department of Obstetrics and Gynaecology, Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Via dell'Istria 65/1 34137, Trieste, Italy
| | - Eran Hadar
- Division of Maternal Fetal Medicine - Helen Schneider's Hospital for Women - Rabin Medical Center, Petah Tikva, Israel
| | - Yariv Yogev
- Division of Maternal Fetal Medicine - Helen Schneider's Hospital for Women - Rabin Medical Center, Petah Tikva, Israel
| | - Moshe Hod
- Division of Maternal Fetal Medicine - Helen Schneider's Hospital for Women - Rabin Medical Center, Petah Tikva, Israel
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Bragg F, Cromwell DA, Edozien LC, Gurol-Urganci I, Mahmood TA, Templeton A, van der Meulen JH. Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk: cross sectional study. BMJ 2010; 341:c5065. [PMID: 20926490 PMCID: PMC2950923 DOI: 10.1136/bmj.c5065] [Citation(s) in RCA: 179] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2010] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine whether the variation in unadjusted rates of caesarean section derived from routine data in NHS trusts in England can be explained by maternal characteristics and clinical risk factors. DESIGN A cross sectional analysis using routinely collected hospital episode statistics was performed. A multiple logistic regression model was used to estimate the likelihood of women having a caesarean section given their maternal characteristics (age, ethnicity, parity, and socioeconomic deprivation) and clinical risk factors (previous caesarean section, breech presentation, and fetal distress). Adjusted rates of caesarean section for each NHS trust were produced from this model. SETTING 146 English NHS trusts. Population Women aged between 15 and 44 years with a singleton birth between 1 January and 31 December 2008. MAIN OUTCOME MEASURE Rate of caesarean sections per 100 births (live or stillborn). RESULTS Among 620 604 singleton births, 147 726 (23.8%) were delivered by caesarean section. Women were more likely to have a caesarean section if they had had one previously (70.8%) or had a baby with breech presentation (89.8%). Unadjusted rates of caesarean section among the NHS trusts ranged from 13.6% to 31.9%. Trusts differed in their patient populations, but adjusted rates still ranged from 14.9% to 32.1%. Rates of emergency caesarean section varied between trusts more than rates of elective caesarean section. CONCLUSION Characteristics of women delivering at NHS trusts differ, and comparing unadjusted rates of caesarean section should be avoided. Adjusted rates of caesarean section still vary considerably and attempts to reduce this variation should examine issues linked to emergency caesarean section.
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Affiliation(s)
- Fiona Bragg
- London School of Hygiene and Tropical Medicine, London, UK
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Farrar D, Tuffnell D, Airey R, Duley L. Care during the third stage of labour: a postal survey of UK midwives and obstetricians. BMC Pregnancy Childbirth 2010; 10:23. [PMID: 20492659 PMCID: PMC2885994 DOI: 10.1186/1471-2393-10-23] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Accepted: 05/21/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are two approaches to care during the third stage of labour: Active management includes three components: administration of a prophylactic uterotonic drug, cord clamping and controlled cord traction. For physiological care, intervention occurs only if there is clinical need. Evidence to guide care during the third stage is limited and there is variation in recommendations which may contribute to differences in practice. This paper describes current UK practice during the third stage of labour. METHODS A postal survey of 2230 fellows and members of the Royal College of Obstetricians and Gynaecologists (RCOG) and 2400 members of the Royal College of Midwives was undertaken. Respondents were asked about care during the third stage of labour, for vaginal and caesarean births and their views on the need for more evidence to guide care in the third stage. The data were analysed in Excel and presented as descriptive statistics. RESULTS 1189 (53%) fellows and members of the RCOG and 1702 (71%) midwives responded, of whom 926 (78%) and 1297 (76%) respectively had conducted or supervised births in the last year. 93% (863/926) of obstetricians and 73% (942/1297) of midwives report 'always or usually' using active management. 66% (611/926) of obstetricians and 33% (430/1297) of midwives give the uterotonic drug with delivery of the anterior shoulder; this was intramuscular Syntometrine(R) for 79% (728/926) and 86% (1118/1293) respectively. For term births, 74% (682/926) of obstetricians and 41% (526/1297) of midwives clamp the cord within 20 seconds, as do 57% (523/926) and 55% (707/1297) for preterm births. Controlled cord traction was used by 94% of both obstetricians and midwives. For caesarean births, intravenous oxytocin was the uterotonic used by 90% (837/926) of obstetricians; 79% (726/926) clamp the cord within 20 seconds for term births as do 63% (576/926) for preterm births.Physiological management was used 'always or usually' by 2% (21/926) of obstetricians and 9% (121/1297) of midwives. 81% (747/926) of obstetricians and 89% (1151/1297) of midwives thought more evidence from randomised trials was needed; the most popular question was when is best to clamp the cord. CONCLUSIONS Active management of the third stage of labour is widely used by both obstetricians and midwives in the UK. Syntometrine(R) is usually used for vaginal births and oxytocin for caesarean births; when this is given and when the cord is clamped varies.
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Affiliation(s)
- Diane Farrar
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, BD9 6RJ, UK
- Obstetric Epidemiology Group, Centre for Epidemiology and Biostatistics, University of Leeds, Leeds, LS2 9JT, UK
| | - Derek Tuffnell
- Women's and Newborn Unit, Bradford Royal Infirmary, Bradford, BD9 6RJ, UK
| | - Rebecca Airey
- Women's and Newborn Unit, Bradford Royal Infirmary, Bradford, BD9 6RJ, UK
| | - Lelia Duley
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, BD9 6RJ, UK
- Obstetric Epidemiology Group, Centre for Epidemiology and Biostatistics, University of Leeds, Leeds, LS2 9JT, UK
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El Senoun GA, Dowswell T, Mousa HA. Planned home versus hospital care for preterm prelabour rupture of the membranes (PPROM) prior to 37 weeks' gestation. Cochrane Database Syst Rev 2010:CD008053. [PMID: 20393965 PMCID: PMC4170988 DOI: 10.1002/14651858.cd008053.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Preterm prelabour rupture of membranes (PPROM) is associated with increased risk of maternal and neonatal morbidity and mortality. Women with PPROM have been predominantly managed in hospital. It is possible that selected women could be managed at home after a period of observation. The safety, cost and women's views about home management have not been established. OBJECTIVES To assess the safety, cost and women's views about planned home versus hospital care for women with PPROM. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2010) and the reference lists of all the identified articles. SELECTION CRITERIA Randomised and quasi-randomised trials comparing planned home versus hospital management for women with PPROM before 37 weeks' gestation. DATA COLLECTION AND ANALYSIS Two review authors independently assessed clinical trials for eligibility for inclusion, risk of bias, and carried out data extraction. MAIN RESULTS We included two trials (116 women) comparing planned home versus hospital management for PPROM. Overall, the number of included women in each trial was too small to allow adequate assessment of pre-specified outcomes. Investigators used strict inclusion criteria and in both studies relatively few of the women presenting with PPROM were eligible for inclusion. Women were monitored for 48 to 72 hours before randomisation. Perinatal mortality was reported in one trial and there was insufficient evidence to determine whether it differed between the two groups (risk ratio (RR) 1.93, 95% confidence interval (CI) 0.19 to 20.05). There was no evidence of differences between groups for serious neonatal morbidity, chorioamnionitis, gestational age at delivery, birthweight and admission to neonatal intensive care.There was no information on serious maternal morbidity or mortality. There was some evidence that women managed in hospital were more likely to be delivered by caesarean section (RR (random-effects) 0.28, 95% CI 0.07 to 1.15). However, results should be interpreted cautiously as there is a moderate heterogeneity for this outcome (I(2) = 35%). Mothers randomised to care at home spent approximately 10 fewer days as inpatients (mean difference -9.60, 95% CI -14.59 to -4.61) and were more satisfied with their care. Furthermore, home care was associated with reduced costs. AUTHORS' CONCLUSIONS The review included two relatively small studies that did not have sufficient statistical power to detect meaningful differences between groups. Future large and adequately powered randomised controlled trials are required to measure differences between groups for relevant pre-specified outcomes. Special attention should be given to the assessment of maternal satisfaction with care and cost analysis as they will have social and economic implications in both developed and developing countries.
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Affiliation(s)
- Ghada Abou El Senoun
- Department of Obstetrics and Gynaecology, Queen’s Medical Centre, Nottingham University Hospital, Nottingham, UK
| | - Therese Dowswell
- Cochrane Pregnancy and Childbirth Group, School of Reproductive and Developmental Medicine, Division of Perinatal and Reproductive Medicine, The University of Liverpool, Liverpool, UK
| | - Hatem A Mousa
- University Department of Obstetrics and Gynaecology, Fetal and Maternal Medicine Unit, Leicester Royal Infirmary, Leicester, UK
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Abstract
BACKGROUND AND SIGNIFICANCE Women's perceptions of childbirth are defined within sociocultural context. Listening to the voices of women is essential to increase nurses' sensitivity to the needs of childbearing women and help nurses provide culturally competent healthcare. PURPOSE The purpose of this qualitative descriptive study was to identify Australian women's perceptions of giving birth. METHOD Seventeen Australian women who had given birth in the past 12 months participated in audiotaped interviews. Trustworthiness of the findings was ensured. Themes were generated on the basis of rich narrative data. RESULTS Themes included focusing on the moment of birth, being empowered by giving birth, defining the spiritual dimension of giving birth, having a diminished or traumatic birth, feeling concern for the child, coming to know the child, and receiving care: nurses making a difference. IMPLICATIONS FOR CLINICAL PRACTICE Results confirm the findings of other studies suggesting that provision of educational resources and individualized nursing care creates a climate of confidence in childbearing women.
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Current Resources for Evidence-Based Practice, July/August 2008. J Midwifery Womens Health 2008. [DOI: 10.1016/j.jmwh.2008.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
BACKGROUND Accurate prediction of the prognosis of infants with very low birth weight is beneficial both for their parents and for healthcare professionals. METHODS This was a population-based study of all low-birth-weight infants admitted to neonatal units in one region in Japan. The Apgar score at 1 and 5 min and neonatal mortality were retrospectively analyzed to obtain the predictive values of the scores. The results were stratified into two categories by birth weight and three time periods (1980-1986, 1987-1993 and 1994-2000). RESULTS The predictive values improved in the later years, and therefore only the data obtained in the period 1994-2000 were used. A score of less than 5 at 5 min appears to be a good predictor of neonatal mortality in infants with a birth weight between 1500 g and 2499 g (positive likelihood ratio, 17.59 [95% confidence interval (CI) 12.68-24.40]); however, there is no evidence that the score is a good predictor of neonatal mortality in infants with very low birth weight. CONCLUSION In infants with a low birth weight between 1500 g and 2499 g, an Apgar score at 5 min of less than 5 is a good predictor of neonatal mortality. The score is not useful in predicting the short-term prognosis of very low-birth-weight infants.
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Affiliation(s)
- Rintaro Mori
- Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan.
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