Effects of algorithm for diagnosis of active labour: cluster randomised trial

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

BACKGROUND

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

QUESTION OR AIM

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

METHODS

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

FINDINGS

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

DISCUSSION

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

CONCLUSION

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

The purple line and its association with cervical dilatation in labour: A systematic review and meta-analysis

BACKGROUND

There is a growing body of evidence that the presence and length of the purple line could represent a non-invasive method of estimating and determining labour progress.

OBJECTIVES

The primary outcome was to provide a systematic review and meta-analysis on the association between the purple line length and cervical dilatation in active labour. The secondary outcome was to determine the association between the purple line length and the fetal head descent, and to calculate the pooled mean length of the purple line at a cervical dilatation of 3-4 cm and at a cervical dilatation of 9-10 cm.

SEARCH STRATEGY

We searched the Medline, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), Clinical Trials.gov and Cochrane Pregnancy and Childbirth's Trials Register databases from inception till March 25, 2023.

SELECTION CRITERIA

We included observational studies of pregnant women in active first stage of labour who had their labour progress assessed with the use of regular vaginal examinations and who had the occurrence recorded and length of the purple line measured at the same time.

DATA COLLECTION AND ANALYSIS

Two reviewers independently evaluated study eligibility. We used the random effects and fixed effects model for meta-analysis.

MAIN RESULTS

There were six eligible studies included in the systematic review that reported on 982 women in total with the purple line appearing in 760 (77.3%) of cases. We found a moderate positive pooled correlation between the purple line length with cervical dilatation (r = +0.64; 95%CI: 0.41-0.87) and fetal head descent (r = +0.50; 95%CI: 0.32-0.68). For women either in spontaneous or induced labour, the pooled mean length of the purple line was more than 9.4 cm when the cervical dilatation was 9-10 cm, whereas it was more than 7.3 cm when the cervical dilatation was 3-4 cm.

CONCLUSIONS

The purple line is a non-invasive method that may potentially be used as an adjunct in labour progress assessment.

Development and validation of a tool for advising primiparous women during early labour: study protocol for the GebStart Study

INTRODUCTION

Pregnant women experience early labour with different physical and emotional symptoms. Early admission to hospital has been found to be associated with increased intervention and caesarean section rates. However, primiparous women often contact the hospital before labour progresses because they encounter difficulties coping with symptoms of onset of labour on their own. An evidence-based instrument for assessing the individual needs to advise primiparous women during early labour is currently missing. The study aims to develop and validate a tool to inform the joint decision for or against hospital admission.

METHODS AND ANALYSIS

A scale development and validation study will be conducted including following steps: (1) Generation of a pool with 99 items based on a scoping review and focus group discussions with primiparous women, (2) Assessment of content and face validity by an expert panel and item reduction to 32 items, (3) Multicentre data collection in six study sites in Switzerland, with application of the preliminary tool and the validation items with a target sample size of approximately n=400 women and (4), item reduction using exploratory factor analysis, factor loading and item-to-item correlation. Internal consistency of the tool will be assessed using Cronbach's alpha and convergent validity computing correlations of items of the tool with the German versions of the Childbirth Self-Efficacy Inventory and the Cambridge-Worry Scale. Analyses will be performed using Stata V.17.

ETHICS AND DISSEMINATION

Ethical approval was obtained by the Ethics Committees Zurich and Northwestern and Central Switzerland (BASEC-Nr. 2021-00687). Results will be disseminated at the final study conference, at national and international congresses and by peer reviewed and not peer-reviewed articles in scientific and professional journals. Approved and anonymised data will be shared. The dissemination of the findings will have a contributable impact on clinical practice, scientific discussions and future research.

TRIAL REGISTRATION NUMBER

DRKS00025572, SNCTP000004555.

Exploring pain characteristics in nulliparous women; A precursor to developing support for women in the latent phase of labour

BACKGROUND

Admission to hospital in the latent phase of labour is associated with a cascade of unnecessary intervention. Women who seek early hospital admission may have heightened fear and anxiety in relation to pain routed in their pre-pregnancy experiences.

OBJECTIVE

To determine the prevalence of pain catastrophising in a healthy non-pregnant population and explore previous pain experiences and fear of childbirth as characteristics that might predict pain catastrophising.

DESIGN

Prospective observational study across two higher education institutions in Scotland and England using a semi-structured survey administered through Bristol Online Surveys. Four validated questionnaires were used to identify the prevalence of pain catastrophising and fear of childbirth in nulliparous women of reproductive age.

RESULTS

The survey was completed by 122 women undertaking an undergraduate degree and aged between 18 and 23 years. A high prevalence of pain catastrophising was found: a cut-off score of 20 and above = 47.5% (58/122 participants), a cut-off score of 30 and above = 21.3% (26/122). Fear of pain (β = 0.14, t = 4.21, p <0 .001) and pain-related anxiety (β = 0.40, t = 11.39, p <0 .001) were significant predictors of pain catastrophisation. However, there was no correlation between fear of childbirth and pain catastrophisation.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

It is reasonable to hypothesise that the pain catastrophising scale may be a good tool to predict those women likely to require additional support in the latent phase of labour; however further work is needed to explore this with a group of pregnant women.

Maximin design of cluster randomized trials with heterogeneous costs and variances

Cluster randomized trials evaluate the effect of a treatment on persons nested within clusters, with clusters being randomly assigned to treatment. The optimal sample size at the cluster and person level depends on the study cost per cluster and per person, and the outcome variance at the cluster and the person level. The variances are unknown in the design stage and can differ between treatment arms. As a solution, this paper presents a Maximin design that maximizes the minimum relative efficiency (relative to the optimal design) over the variance parameter space, for trials with two treatment arms and a quantitative outcome. This maximin relative efficiency design (MMRED) is compared with a published Maximin design which maximizes the minimum efficiency (MMED). Both designs are also compared with the optimal designs for homogeneous costs and variances (balanced design) and heterogeneous costs and homogeneous variances (cost-conscious design), for a range of variances based upon three published trials. Whereas the MMED is balanced under high uncertainty about the treatment-to-control variance ratio, the MMRED then tends towards a balanced budget allocation between arms, leading to an unbalanced sample size allocation if costs are heterogeneous, similar to the cost-conscious design. Further, the MMRED corresponds to an optimal design for an intraclass correlation (ICC) in the lower half of the assumed ICC range (optimistic), whereas the MMED is the optimal design for the maximum ICC within the ICC range (pessimistic). Attention is given to the effect of the Welch-Satterthwaite degrees of freedom for treatment effect testing on the design efficiencies.

Variations in outcomes for women admitted to hospital in early versus active labour: an observational study

Background

There is no available evidence for the prevalence of early labour admission to hospital or its association with rates of intervention and clinical outcomes in Australia. The objectives of this study were to: estimate the prevalence of early labour admission in one hospital in Australia; compare rates of clinical intervention, length of hospital stay and clinical outcomes for women admitted in early (< 4 cm cervical dilatation) or active (≥4 cm) labour; and determine the impact of recent recommendations to define early labour as < 5 cm on the findings.

Methods

We conducted a retrospective cohort study using medical record data from a random sample of 1223 women from live singleton births recorded between July 2013 and December 2015. Analyses included women who had spontaneous onset of labour at ≥37 weeks gestation whilst not a hospital inpatient, who had not scheduled a caesarean section before labour onset or delivered prior to hospital admission. Associations between timing of hospital admission in labour and clinical intervention, outcomes and hospital stay were assessed using logistic regression.

Results

Between 32.4% (< 4 cm) and 52.9% (< 5 cm) of eligible women (N = 697) were admitted to hospital in early labour. After adjustment for potential confounders, women admitted in early labour (< 4 cm) were more likely to have their labour augmented by oxytocin (AOR = 3.57, 95% CI 2.39–5.34), an epidural (AOR = 2.27, 95% CI 1.51–3.41), a caesarean birth (AOR = 3.50, 95% CI 2.10–5.83), more vaginal examinations (AOR = 1.73, 95% CI = 1.53–1.95), and their baby admitted to special care nursery (AOR = 1.54, 95% CI = 1.01–2.35). Defining early labour as < 5 cm cervical dilatation produced additional significant associations with artificial rupture of membranes (AOR = 1.41, 95% CI = 1.02–1.95), assisted vaginal birth (AOR = 1.96, 95% CI = 1.12–3.41) neonatal resuscitation (AOR = 1.73, 95% CI = 1.01–2.99) and longer maternal hospital stay (AOR = 1.21, 95% CI = 1.04–1.40).

Conclusions

Findings provide preliminary evidence that a notable proportion of labouring women are admitted in early labour and are more likely to experience several medical procedures, neonatal resuscitation and admission to special care nursery, and longer hospital stay.

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

OBJECTIVE

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

DESIGN

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

SETTING

two urban Australian hospitals in different states.

PARTICIPANTS

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

INTERVENTIONS

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

MEASUREMENTS AND FINDINGS

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

KEY CONCLUSIONS

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

IMPLICATIONS FOR PRACTICE

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

First assessed cervical dilatation: is it associated with oxytocin augmentation during labour? A retrospective cohort study in a university hospital in Switzerland

OBJECTIVES

The primary objective of this study was to examine the association between the first assessed cervical dilatation in a labourward and the use of oxytocin augmentation during labour. Further analysis was performed by examining the actual stage of labour at the point oxytocin was first administered to those women.

DESIGN

Retrospective cohort study with the data collected from the medical records of the hospital.

SETTING

University Hospital Bern, Switzerland PARTICIPANTS: 1933 term nulliparous and multiparous women with a singleton pregnancy giving birth during the period June 2013 and May 2017, representing Robson groups 1 and 3.

MEASUREMENTS AND FINDINGS

Descriptive statistics and multivariable logistic regression models were performed. It was found that for the entire process of labour, nulliparous and multiparous women (n = 1933) with a first cervical dilatation of 5 or more cm were less likely to be augmented with oxytocin (OR 0.64, 95% CI 0.46; 0.88 and OR 0.56, 95% CI 0.38; 0.82, respectively) compared to women with a first cervical dilatation of less than 5 cm. Out of these augmented women (n = 746) having a first cervical dilatation of 5 or more cm, they had a lower likelihood of being augmented during the first stage of labour compared to women with a first cervical dilatation of less than 5 cm (OR 0.45, 95% CI 0.29; 0.7 for nulliparae and OR 0.32, 95% CI 0.16; 0.6 for multiparae). Additionally, it was observed that other factors contributed to the application of oxytocin. One such example was that epidural analgesia was associated with a high risk of oxytocin augmentation in nulliparae (OR 13.88, 95% CI 9.29; 20.74) and multiparae (OR 15.52, 95% CI 9.94; 24.22). The application of oxytocin was also found to affect the caesarean section rate in nulliparous and multiparous women as it was 20% and 13% respectively for those with oxytocin versus 13% and 4% respectively for those without oxytocin.

KEY CONCLUSIONS

Early admission to the labourward is associated with an increased use of oxytocin to augment labour, particularly, during the first stage of labour. Epidural analgesia is a main predictor for oxytocin augmentation in nulliparous and multiparous women.

IMPLICATIONS FOR PRACTICE

Pregnant women warrant more appropriate support during early labour, avoiding early maternal exhaustion and excessive obstetrical interventions.

Admitting women in active labour: A randomised controlled trial about the effects of protocol use on childbirth method and interventions

AIM

To determine the effects of protocol of admitting women in active labour on childbirth method and interventions during labour and childbirth.

METHODS

This single-blind randomised clinical trial was conducted in a public hospital in Mazandaran province (Iran) in 2017. Two hundred nulliparous low-risk women were randomly assigned into intervention and control groups. The participant women were admitted in the intervention group using the admission protocol and to the group control by staff midwives and doctors. The admission criteria of the protocol were: the presence of regular, painful contractions, the cervix at least four cm dilated and at least one of the following cues: cervix effaced, and spontaneous rupture of membranes, or "show". The primary outcome measure was childbirth method. Data were analyzed in SPSS-22 using Mann-Whitney and Chi-square tests. The level of statistical significance was set as p<0.05.

FINDING

There were significant differences between the intervention and control groups in the number of caesarian section (CS) (p<0.001). Two groups had a statistically significant difference in amniotomy (p=0.003), augmentation by oxytocin (p<0.001), number of vaginal examinations (p<0.001) and fundal pressure (p<0.001).

CONCLUSIONS

Using a protocol for admission of low risk nulliparous women in active labour contributed to reduction of the primary caesarean section rate and interventions during childbirth. A risk assessment and using evidence informed guidelines in admission can contribute to reduce unsafe and harmful practices and support normalisation of birth. This is essential for demedicalisation and a useful strategy for reducing primary CS.

Does introducing a dedicated early labour area improve birth outcomes? A pre-post intervention study

PROBLEM

Women increasingly present to hospital in early labour, but admission before active labour contributes to overuse of interventions, poorer clinical and psychological outcomes, and higher healthcare costs.

BACKGROUND

Innovative models of early labour care have so far not improved birth outcomes.

AIM

To examine if reconfiguring the early labour service in a large Australian maternity service improved (1) the birth outcomes of women who presented in early labour and (2) alleviated bed blockages by decreasing length of stay in the Pregnancy Assessment and Observation Unit.

METHODS

Pre-post intervention design, using routinely collected clinical data before and after the implementation of the reconfigured early labour service.

FINDINGS

There were 527 women in pre-intervention cohort and 747 in the post-intervention cohort. The two groups were similar in age, body mass index, marital status, education level and gestation at birth. Post intervention, epidural use did not change significantly, but rates of amniotomy (35.7% vs. 49.9%, p = <0.001), meconium-stained liquor (20.1% vs 26.1%, p = 0.04), and neonatal nursery admission (2.7% vs. 5.8% p =  0.01) increased. The proportion of women staying in the Assessment unit more than two hours decreased, but not significantly.

CONCLUSION

Changing the location and model of early labour care did not influence epidural use, nor improve women's birth outcomes. For women in early labour, admission to any location within the hospital may be as problematic as admission to birth suite specifically.

Women's experiences of induction of labour: Qualitative systematic review and thematic synthesis

OBJECTIVES

To explore and synthesise evidence of women's experiences of induction of labour (IoL).

DESIGN

Systematic review and thematic synthesis of peer-reviewed qualitative evidence. Relevant databases were searched from inception to the present day. Study quality was appraised using the Critical Appraisal Skills Programme (CASP) qualitative research appraisal tool.

SETTING AND PARTICIPANTS

Low and high risk women who had experienced IoL in an inpatient or outpatient setting.

FINDINGS

Eleven papers (representing 10 original studies) published between 2010 and 2018 were included for thematic synthesis. Four key analytical themes were identified: ways in which decisions regarding induction were made; women's ownership of the process; women's social needs when undergoing IoL; and the importance of place in the induction process. The review indicates that IoL is a challenging experience for women, which can be understood in terms of the gap between women's needs and the reality of their experience concerning information and decision-making, support, and environment.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Providing good quality appropriately timed information and supporting women's self-efficacy to be involved in decision-making around IoL may benefit women by facilitating a sense of ownership or control of labour. Compassionate support from significant others and healthcare professionals in a comfortable, private and safe environment should be available to all women.

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

OBJECTIVES

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

DESIGN

a systematic review of qualitative evidence.

SETTING AND PARTICIPANTS

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

FINDINGS

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

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

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

Exploring midwives' interactions with mothers when labour begins: A study using participatory action research

OBJECTIVE

to explore the interactions between mothers and midwives when labour begins with a focus on midwives and unexpected birth out of hospital.

DESIGN

participatory action research (PAR) that sought to understand and improve interactions between mothers and midwives through interviews, focus groups and a joint workshop.

SETTING

maternity services in the north of England, in a district general hospital with one obstetric unit and two birth centres, across two sites and where there was a birth rate of 6000.

PARTICIPANTS

a total of 72 participants took part in the study. Thirteen mothers and five midwives were interviewed. Seven mothers were interviewed who had contacted a midwife in labour and subsequently given birth unexpectedly out of hospital. Thirty-one mothers and twenty-three midwives took part in a series of ten focus groups.

KEY FINDINGS

three major themes were identified from the midwives' data: 'Formulaic discourse as self-protection', 'One to one or one to everyone' and 'Interactions and time'. The latter theme is discussed in this paper showing that when midwifery activity was high and they did not have enough time, midwives experienced a high degree of conflicting emotions such as fear, helplessness and frustration, which stretched their personal and professional integrity and triggered changes in their thinking and behaviour.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

current maternity services appear constrained by a reduced midwifery workforce that is expected to meet excessive organisational demands whilst coping with reduced bed capacity. These pressures can promote changes in midwives' behaviour and thinking which disconnects them from mothers rather than focussing on their needs. Safety depends on a high degree of midwife to mother continuity. However, a business model approach, prioritising throughput and process promotes fragmented care and can potentially threaten the safety of mothers and babies. In this study, there appears to be a link between disconnected interactions when labour begins and mothers giving birth unexpectedly out of hospital.

Sociodemographic differences in women's experience of early labour care: a mixed methods study

OBJECTIVES

To explore women's experiences of early labour care focusing on sociodemographic differences, and to examine the effect of antenatal education, using mixed methods.

SETTING

England, 2014.

PARTICIPANTS

Women who completed postal questionnaires about their experience of maternity care, including questions about antenatal education, early labour and sociodemographic factors, included space for free-text comments.

OUTCOME MEASURES

Worries about labour, contact with midwives in early labour and subsequent care.

METHODS

This study was based on secondary analysis of a national maternity survey carried out in England in 2014. Quantitative data were analysed using descriptive statistics and binary logistic regression; qualitative data were analysed using a thematic content analytic approach.

RESULTS

Completed questionnaires were received from 4578 women (47% response rate). There were significant differences by sociodemographic factors, particularly ethnicity, in women's worries about early labour. Compared with white women, women from black or minority ethnic groups had an adjusted OR of 1.93 (95% CI 1.56 to 2.39) of feeling worried about not knowing when labour would start. Among women who contacted a midwife at the start of labour, 84% perceived their advice as appropriate, more in older and multiparous women. Overall, 64% of women were asked to come to the hospital at this time, more in multiparous women (adjusted OR 1.63, 95% CI 1.35 to 1.96). Those who did not have access to antenatal education experienced greater worry about early labour. Five themes emerged from the qualitative analysis: 'Differentiating between early and active labour', 'Staff attitudes', 'Not being allowed…', 'Previous labours' and 'Perceived consequences for women'.

CONCLUSION

These findings reinforce the importance of providing reassurance to women in early labour, taking care that women do not feel neglected or dismissed. In particular, primiparous and ethnic minority women reported greater worry about early labour and require additional reassurance.

Assessment and support during early labour for improving birth outcomes

BACKGROUND

The progress of labour in the early or latent phase is usually slow and may include painful uterine contractions. Women may feel distressed and lose their confidence during this phase. Support and assessment interventions have been assessed in two previous Cochrane Reviews. This review updates and replaces these two reviews, which have become out of date.

OBJECTIVES

To investigate the effectiveness of assessment and support interventions for women during early labour.In order to measure the effectiveness of the interventions, we compared the duration of labour, the rate of obstetrical interventions, and the rate of other maternal or neonatal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (31 October 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials of any assessment or support intervention in the latent phase of labour. We planned to include cluster-randomised trials if they were eligible. We did not include quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We resolved any disagreement by discussion or by involving a third assessor. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

We included five trials with a total of 10,421 pregnant women in this review update. The trials were conducted in the UK, Canada and America. The trials compared interventions in early labour versus usual care. We examined three comparisons: early labour assessment versus immediate admission to hospital; home visits by midwives versus usual care (telephone triage); and one-to-one structured midwifery care versus usual care. These trials were at moderate- risk of bias mainly because blinding women and staff to these interventions is not generally feasible. For important outcomes we assessed evidence using GRADE; we downgraded evidence for study design limitations, imprecision, and where we carried out meta-analysis, for inconsistency.One trial with 209 women compared early labour assessment with direct admission to hospital. Duration of labour from the point of hospital admission was reduced for women in the assessment group (mean difference (MD) -5.20 hours, 95% confidence interval (CI) -7.06 to -3.34; 209 women, low-quality evidence). There were no clear differences between groups for the number of women undergoing caesarean section or instrumental vaginal birth (risk ratio (RR) 0.72, 95% CI 0.30 to 1.72, very low quality evidence; and, RR 0.86, 95% CI 0.58 to 1.26, very low quality evidence, respectively). Serious maternal morbidity was not reported. Women in the early assessment group were slightly less likely to have epidural anaesthesia (RR 0.87, 95% CI 0.78 to 0.98, low-quality evidence), and considerably less likely to have oxytocin for labour augmentation (RR 0.57, 95% CI 0.37 to 0.86) and this group also had increased satisfaction with their care compared with women in the immediate admission group (MD 16.00, 95% CI 7.53 to 24.47). No babies were born before admission to hospital and only one infant had a low Apgar score at five minutes after the birth (very low quality evidence). Admission to neonatal special care was not reported.Three studies examined home assessment and midwifery support versus telephone triage. One trial reported the duration of labour; home visits did not appear to have any clear impact compared with usual care (MD 0.29 hours, 95% CI -0.14 to 0.72; 1 trial, 3474 women, low-quality evidence). There was no clear difference for the rate of caesarean section (RR 1.05, 95% CI 0.95 to 1.17; 3 trials, 5170 women; I² = 0%; moderate-quality evidence) or the rate of instrumental vaginal birth (average RR 0.95, 95% CI 0.79 to 1.15; 2 trials, 4933 women; I² = 69%; low-quality evidence). One trial reported birth before arrival at hospital or unplanned home birth; there was no clear difference between the groups (RR 1.33, 95% CI 0.30 to 5.95; 1 trial, 3474 women). No clear differences were identified for serious maternal morbidity (RR 0.93, 95% CI 0.61 to 1.42; 1 trial, 3474 women; low-quality evidence), or use of epidural (average RR 0.95, 95% CI 0.87 to 1.05; 3 trials, 5168 women; I² = 60%; low-quality evidence). There were no clear differences for neonatal admission to special care (average RR 0.84, 95% CI 0.50 to 1.42; 3 trials, 5170 infants; I² = 71%; very low quality evidence), or for Apgar score less than seven at five minutes after birth (RR 1.19, 95% CI 0.71 to 1.99; 3 trials, 5170 infants; I² = 0%; low-quality evidence).One study, with 5002 women, examined one-to-one structured care in early labour versus usual care. Length of labour was not reported. There were no clear differences between groups for the rate of caesarean section (RR 0.93, 95% CI 0.84 to 1.02; 4996 women, high-quality evidence), or for instrumental vaginal birth (RR 0.94, 95% CI 0.82 to 1.08; 4996 women, high-quality evidence). No clear differences between groups were reported for serious maternal morbidity (RR 1.13, 95% CI 0.84 to 1.52; 4996 women, moderate-quality evidence). Use of epidural was similar in the two groups (RR 1.00, 95% CI 0.99 to 1.01; 4996 women, high-quality evidence). For infant outcomes, there were no clear differences between groups (admission to neonatal intensive care unit: RR 0.98, 95% CI 0.80 to 1.21; 4989 infants, high-quality evidence; Apgar score less than seven at five minutes: RR 1.07, 95% CI 0.64 to 1.79; 4989 infants, moderate-quality evidence).

AUTHORS' CONCLUSIONS

Assessment and support in early labour does not have a clear impact on rate of caesarean section or instrumental vaginal birth, or whether the baby was born before arrival at hospital or in an unplanned home birth. However, evidence suggested that interventions may have an impact on reducing the use of epidural anaesthesia, labour augmentation and on increasing maternal satisfaction with giving birth. Evidence about the effectiveness of early labour assessment versus immediate admission was very limited and more research is needed in this area.

Perspectives on Promoting Hospital Primary Vaginal Birth: A Qualitative Study

BACKGROUND

One in three women will deliver by cesarean, a procedure that can be life saving, but which also carries short- and long-term risks. There is growing interest in preventing primary cesarean deliveries, while optimizing the health of the mother and infant. The primary aim of this study was to use participatory action strategies and ethnographic interview data collected from diverse stakeholders in birth (caregivers, women, policymakers) about facilitators and barriers to the achievement of primary vaginal birth in first-time mothers in hospital settings. The secondary aim was to use the findings to identify strategies to promote primary vaginal birth and future areas of research.

METHODS

Individual and small group interviews were conducted with caregivers and policymakers (N = 79) and first-time mothers (N = 24) at a northeastern hospital. All interviews were audio-recorded, transcribed, and analyzed using Atlas.ti.

RESULTS

Four broad themes were identified: 1) preparation for childbirth, 2) early labor management, 3) caregiver knowledge and practice style, and 4) birth environment (physical, cultural/emotional). The first two were closely linked from caregivers' perspectives. If the woman was not prepared for childbirth, it was perceived she would be more likely to present to the hospital in early labor. Once there, it was hard to prevent admission and interventions. A woman's knowledge and confidence were perceived as powerful mediators for vaginal birth.

CONCLUSION

Caregivers and first-time mothers identified early labor management and childbirth preparation as important factors to promote primary vaginal birth in hospital settings. Both deserve further inquiry as potential strategies to decrease rising cesarean delivery rates.

Early versus Late Admission to Labor Affects Labor Progression and Risk of Cesarean Section in Nulliparous Women

Background

Rates of cesarean section increase worldwide, and the components of this increase are partially unknown. A strong role is prescribed to dystocia, and at the same time, the diagnosis of dystocia is highly subjective. Previous studies indicated that risk of cesarean is higher when women are admitted to the hospital early in the labor.

Methods

We examined data on 1,202 nulliparous women with singleton, vertex pregnancies and spontaneous labor onset. We selected three groups based on cervical dilatation at admission: early (0.5–1.5 cm, N = 178), intermediate (2.5–3.5 cm, N = 320), and late (4.5–5.5 cm, N = 175). The Kaplan–Meier estimator was used to analyze the risk of delivery by cesarean section at a given dilatation, and thin-plate spline regression with a binary outcome (R library gam) to assess the form of the associations between the cesarean section in either the first or second stage versus vaginal delivery and dilatation at admission.

Results

Women who were admitted to labor early had a higher risk of delivery by cesarean section (18 versus 4% in the late admission group), while the risk of instrumental delivery did not differ (24 versus 24%). Before 4 cm dilatation, the earlier a woman was admitted to labor, the higher was her risk of delivery by cesarean section. After 4 cm dilatation, however, the relationship disappeared. These patterns were true for both first and second stage cesarean deliveries. Oxytocin use was associated with a higher risk of cesarean section only in the middle group (2.5–3.5 cm dilatation at admission).

Conclusion

Early admission to labor was associated with a significantly higher risk of delivery by cesarean section during the first and second stages. Differential effects of oxytocin augmentation depending on dilation at admission may suggest that admission at the early stage of labor is an indicator rather than a risk factor itself, but admission at the intermediate stage (2.5–3.5 cm) becomes a risk factor itself. Further research is needed to study this hypothesis.

Midwifery practice during birth: Ritual companionship

BACKGROUND

There is an expectation that midwifery practice is woman centred and promotes physiology. In addition, midwives must assess the wellbeing of mother and baby, and monitor the progress of labour. It is important to understand how midwifery actions and interactions influence the birth experience for women.

AIM

The aim of this study was to explore midwifery practice during physiological birth from the perspective of both midwives and mothers.

METHOD

A narrative inquiry involving face-to-face in-depth interviews was used to gather data. The participants were 10 midwives and 10 women who had recently attended or experienced an uncomplicated physiological birth. Data was analysed to identify themes occurring across the narratives.

FINDINGS

Two types of midwifery practice were identified from the data: rites of passage and rites of protection. Rites of passage were synergistic with women's needs during birth and involved managing distractions and reflecting internal wisdom. Rites of protection involved performing clinical assessments to determine wellbeing and labour progress. These practices could contradict the rites of passage by disrupting aloneness and reinforcing external wisdom.

CONCLUSION

Midwives performed two types of practices which intersected with women's experience of birth in differing and contested ways. Conceptualising the role of the midwife as a 'ritual companion' and actions and words as rituals enables a deeper exploration of the values transmitted and reflected by midwifery practice. This study contributes to a discourse about midwifery practice during birth, women's experience of birth, and the influence of the institution on the nature of mother-midwife relationship.

Labour management and Obstetric outcomes among pregnant women admitted in latent phase compared to active phase of labour at Bugando Medical Centre in Tanzania

Background

Interventions given to women admitted in latent or active phase of labor may influence the outcomes of labor and ameliorate complications which can affect the mother and fetus. Labour management, maternal and fetal outcomes among low risk women presenting both in latent phase and active phase of labour in Tanzania have not recently been explored.

Methods

This was a descriptive cross-sectional study. It was done from February to April 2013. Case notes were collected serially until the sample size was reached. A structured checklist was used to extract data. Data was analyzed using SPSS version 17. A p < 0.05 was considered significant at 95% confidence interval.

Results

Five hundred case notes of low risk pregnant women were collected, half of each presented in latent phase and active phase of labour. Key interventions including augmentation with oxytocin, artificial rupture of membranes and caesarean section were significantly higher in the latent phase group than the active phase group 84(33.6%) versus 52(20.8%) p < 0.05; 96(38.6%) versus 56(22.4%) p < 0.05 and 87(34.8%) versus 60(24.0%) p < 0.05 respectively. Spontaneous vertex delivery was higher among pregnant women admitted initially in active phase than in latent phase groups 180(72.0%), versus 153(61.2%) p > 0.01). There were more women in the active phase group who sustained genital tract tear and postpartum haemorrhage than in the latent phase group 101(18.6%), versus 38(15.6%) p < 0.01 and 46(18.4%), versus 17(6.6%) p < 0.05 respectively.

Conclusions

Pregnant women admitted at BMC in latent phase of labour are subjected to more obstetric interventions than those admitted in the active phase. There is need to produce guidelines on management of women admitted in latent phase of labour at BMC to reduce the risk of unnecessary interventions.

Multiple imputation methods for handling missing data in cost-effectiveness analyses that use data from hierarchical studies: an application to cluster randomized trials

PURPOSE

Multiple imputation (MI) has been proposed for handling missing data in cost-effectiveness analyses (CEAs). In CEAs that use cluster randomized trials (CRTs), the imputation model, like the analysis model, should recognize the hierarchical structure of the data. This paper contrasts a multilevel MI approach that recognizes clustering, with single-level MI and complete case analysis (CCA) in CEAs that use CRTs.

METHODS

We consider a multilevel MI approach compatible with multilevel analytical models for CEAs that use CRTs. We took fully observed data from a CEA that evaluated an intervention to improve diagnosis of active labor in primiparous women using a CRT (2078 patients, 14 clusters). We generated scenarios with missing costs and outcomes that differed, for example, according to the proportion with missing data (10%-50%), the covariates that predicted missing data (individual, cluster-level), and the missingness mechanism: missing completely at random (MCAR), missing at random (MAR), or missing not at random (MNAR). We estimated incremental net benefits (INBs) for each approach and compared them with the estimates from the fully observed data, the "true" INBs.

RESULTS

When costs and outcomes were assumed to be MCAR, the INBs for each approach were similar to the true estimates. When data were MAR, the point estimates from the CCA differed from the true estimates. Multilevel MI provided point estimates and standard errors closer to the true values than did single-level MI across all settings, including those in which a high proportion of observations had cost and outcome data MAR and when data were MNAR.

CONCLUSIONS

Multilevel MI accommodates the multilevel structure of the data in CEAs that use cluster trials and provides accurate cost-effectiveness estimates across the range of circumstances considered.

Vaginal Examination During Normal Labor: Routine Examination or Routine Intervention?

Despite a continuing lack of good quality studies of the effect of routine vaginal examination, it is often routinely used in clinical practice. Indeed, internationally respected authorities such as the U.K. National Institute for Health and Clinical Excellence (NICE) continue to recommend the offer of a vaginal examination when a woman enters a hospital in suspected established labor and 4 hourly vaginal examinations as labor progresses. In this article, we explore historical and clinical drivers for the widespread implementation of routine vaginal examination in labor to predominantly assess the dilation of the cervical os and examine some of the reasons for continuing use of the procedure, current critiques of its routine use, and possible alternatives for assessing labor progress. We discuss the possibility that both covert and overt knowledge operate in the assessment of labor progress, and we consider the consequent potential for dissonance between what midwives actually do and what they record as having been done. The final discussion theorizes these findings and suggests alternative ways of framing labor progress for the future.

Women's perception of the onset of labour and epidural analgesia: a prospective study

OBJECTIVE

childbearing women and their midwives differ in their diagnoses of the onset of labour. The symptoms women use to describe the onset of labour are associated with the process of labour. Perinatal factors and women's attitudes may be associated with the administration of epidural analgesia. Our study aimed to assess the correlation between women's perception of the onset of labour and the frequency and timing of epidural analgesia during labour.

DESIGN

prospective cohort study.

SETTING

41 maternity units in Lower Saxony, Germany.

PARTICIPANTS

549 nulliparae (as defined in the "Methods" section) and 490 multiparae giving birth between April and October 2005. Women were included after 34 completed weeks of gestation with a singleton in vertex presentation and planned vaginal birth.

MEASUREMENTS

the association between women's symptoms at the onset of labour and the administration of epidural analgesia - frequency, timing in relation to onset of labour and cervical dilatation - was assessed. The analysis was performed by Kaplan-Meiers estimation, logistic regression and Cox regression.

FINDINGS

a total of 174 nulliparae and 49 multiparae received epidural analgesia during labour. Nulliparae received it at a median time of 5.47hrs (range: 0.25-51.17hrs) after onset of labour, at a median cervical dilatation of 3.3cm (range: 1.0-10.0cm). In multiparae, epidural analgesia was applied at a median time of 3.79hrs (range: 0.42-28.55hrs) after onset of labour; the median cervical dilatation was 3.0cm (range: 1.0-8.0cm). Women who were admitted with advanced cervical dilatation received epidural analgesia less often. Women who defined their onset of labour earlier than it was diagnosed by their midwives received epidural analgesia earlier. Gastrointestinal symptoms and irregular pain at the onset of labour were associated with later administration of epidural analgesia. Induction of labour was associated with a reduced interval from the onset of labour to epidural analgesia.

KEY CONCLUSIONS

women's self-diagnosis of the onset of labour and their perception of their labour duration when meeting their midwives has some impact on their admission to the labour ward and the timing of epidural analgesia.

IMPLICATIONS FOR PRACTICE

consideration of women's own perceptions and expectations regarding the onset and process of labour is necessary for individual care during labour.

Development and psychometric properties of the Early Labour Experience Questionnaire (ELEQ)

OBJECTIVE

to describe the development and psychometric properties of the Early Labour Experiences Questionnaire (ELEQ).

DESIGN

randomized controlled trial.

SETTING

hospitals serving obstetric populations in metropolitan and suburban Vancouver, British Columbia, Canada.

PARTICIPANTS

423 healthy nulliparous women in labour at term with uncomplicated pregnancies.

INTERVENTION

women were randomized to telephone support (n=241) or home visit (n=182) study groups and completed the ELEQ during the postpartum phase of their hospital stay.

MEASUREMENT

the ELEQ contains 26 self-report items, rated on a 5-point scale, that measure women's affective experience of early labour (14 items), perceptions of nursing care (12 items), whether they would recommend this type of early labour care to a friend (1 item), and whether they believed they went to the hospital at the right time (1 item). An exploratory factor analysis was conducted to determine whether the items grouped together into subscales. The structural reliability of the extracted subscales and total scores were evaluated using a number of coefficients. To test criterion validity, we compared ELEQ item, subscale and total scores between the study groups.

FINDINGS

item and total scores showed significant variability. Factor analysis yielded three subscales: Emotional Well-Being, Emotional Distress and Perceptions of Nursing Care. The subscale and total scores showed good internal consistency and item homogeneity, and were interrelated in the expected direction. Items evidenced strong associations with the subscale and total scores. Comparisons between study groups offered some support for criterion validity.

KEY CONCLUSIONS

pending further validation, the ELEQ can contribute to the assessment of women's experiences with different aspects of maternity care, evaluation of the quality of maternity care, and improvement of maternity services.

Developing appropriate methods for cost-effectiveness analysis of cluster randomized trials

AIM

Cost-effectiveness analyses (CEAs) may use data from cluster randomized trials (CRTs), where the unit of randomization is the cluster, not the individual. However, most studies use analytical methods that ignore clustering. This article compares alternative statistical methods for accommodating clustering in CEAs of CRTs.

METHODS

Our simulation study compared the performance of statistical methods for CEAs of CRTs with 2 treatment arms. The study considered a method that ignored clustering--seemingly unrelated regression (SUR) without a robust standard error (SE)--and 4 methods that recognized clustering--SUR and generalized estimating equations (GEEs), both with robust SE, a "2-stage" nonparametric bootstrap (TSB) with shrinkage correction, and a multilevel model (MLM). The base case assumed CRTs with moderate numbers of balanced clusters (20 per arm) and normally distributed costs. Other scenarios included CRTs with few clusters, imbalanced cluster sizes, and skewed costs. Performance was reported as bias, root mean squared error (rMSE), and confidence interval (CI) coverage for estimating incremental net benefits (INBs). We also compared the methods in a case study.

RESULTS

Each method reported low levels of bias. Without the robust SE, SUR gave poor CI coverage (base case: 0.89 v. nominal level: 0.95). The MLM and TSB performed well in each scenario (CI coverage, 0.92-0.95). With few clusters, the GEE and SUR (with robust SE) had coverage below 0.90. In the case study, the mean INBs were similar across all methods, but ignoring clustering underestimated statistical uncertainty and the value of further research.

CONCLUSIONS

MLMs and the TSB are appropriate analytical methods for CEAs of CRTs with the characteristics described. SUR and GEE are not recommended for studies with few clusters.

Women's preferences for aspects of labor management: results from a discrete choice experiment

BACKGROUND

The latent phase of labor can vary greatly in duration, and many women are uncertain about when to contact the maternity unit. The aim of this study was to elicit and value women's preferences for some aspects of labor management.

METHODS

A questionnaire was sent to 1,251 women who had recently given birth to their first child at one of 14 maternity units in Scotland. Discrete choice questions were used to measure women's preferences for five attributes of care: number of visits (assessments) before admission to the labor ward, time spent on the labor ward before delivery, mobility during labor, pain relief required, and mode of delivery. Responses were analyzed for the sample as a whole and for subgroups defined by recent experiences of labor.

RESULTS

A total of 730 (58.4%) questionnaires were returned and analyzed. Women expressed a preference for fewer visits before admission, shorter times on the labor ward before delivery, mobility during labor, normal vaginal deliveries, and moderate forms of pain relief (Entonox and opiates). Subgroup analysis suggests that women's preferences for pain relief are influenced by their recent labor experience. The elicited preference values provide a means for estimating the tradeoffs women are willing to make between attributes of labor management.

CONCLUSIONS

Women appear to dislike being turned away from the labor ward before admission for delivery. Extra visits before admission only appear to be a price worth paying if they result in reductions in the duration of time spent on the labor ward, reductions in the chance of being immobilized in hospital during labor, or a lower chance of requiring an instrumental or operative delivery.

The development of research tools used in the STORK Study (the Scottish Trial of Refer or Keep) to explore midwives' intrapartum decision making

OBJECTIVES

to develop appropriate tools to assess midwives' attitudes and behaviour in relation to decision making involving risk.

DESIGN

a questionnaire and series of vignettes were developed and testes to explore midwives' intrapartum decision making in relation to their attitudes towards risk. An innovative online computer package was developed specifically for use in the STORK Study which enabled the programme to be very tightly controlled with limited functions accessible to participants.

TESTING

a pilot study was conducted with over 50 midwives and nurses to ensure face and content validity of the vignettes and questionnaire. Initially designed to be a paper-based study, rigorous piloting highlighted the many difficulties in presenting it in that particular format. The solution to this problem was to develop the study as a secure online package.

FINDINGS

online data collection provided the researchers with a greater degree of control of the data collection process, not achievable using traditional paper survey methods. Another example of this control is the immediate entry of data from participants' responses to a background database which automatically stores and backs up data this means that no additional time is required for data entry. The cost of employing an information technology professional was easily offset by the financial savings made through the limited use of stationery and postage.

KEY CONCLUSIONS

although the development and testing of the research tools for the STORK Study was labour and time intensive, ultimately a questionnaire and vignette package was produced that had been rigorously tested by over 50 midwives and nurses. The researchers are confident in the reliability of the questionnaire and vignettes, as well as the validity of the data collected. The use of an online survey is clearly indicated when the population has readily available internet access, and where controlling the process of data collection is required, as such control cannot be achieved in traditional survey and questionnaire implementation.

The purple line as a measure of labour progress: a longitudinal study

Background

Vaginal examination (VE) and assessment of the cervix is currently considered to be the gold standard for assessment of labour progress. It is however inherently imprecise with studies indicating an overall accuracy for determining the diameter of the cervix at between 48-56%. Furthermore, VEs can be unpleasant, intrusive and embarrassing for women, and are associated with the risk of introducing infection. In light of increasing concern world wide about the use of routine interventions in labour it may be time to consider alternative, less intrusive means of assessing progress in labour. The presence of a purple line during labour, seen to rise from the anal margin and extend between the buttocks as labour progresses has been reported. The study described in this paper aimed to assess in what percentage of women in labour a purple line was present, clear and measurable and to determine if any relationship existed between the length of the purple line and cervical dilatation and/or station of the fetal head.

Methods

This longitudinal study observed 144 women either in spontaneous labour (n = 112) or for induction of labour (n = 32) from admission through to final VE. Women were examined in the lateral position and midwives recorded the presence or absence of the line throughout labour immediately before each VE. Where present, the length of the line was measured using a disposable tape measure. Within subjects correlation, chi-squared test for independence, and independent samples t-test were used to analyse the data.

Results

The purple line was seen at some point in labour for 109 women (76%). There was a medium positive correlation between length of the purple line and cervical dilatation (r = +0.36, n = 66, P = 0.0001) and station of the fetal head (r = +0.42, n = 56, P < 0.0001).

Conclusions

The purple line does exist and there is a medium positive correlation between its length and both cervical dilatation and station of the fetal head. Where the line is present, it may provide a useful guide for clinicians of labour progress along side other measures. Further research is required to assess whether measurement of the line is acceptable to women in labour and also clinicians.

So you want to conduct a cluster randomized controlled trial? Lessons from a national cluster trial of early labour

As the discipline of health services research has developed so methods of evaluation have become increasingly sophisticated; where once a 'simple' randomized controlled trial would have been considered the gold standard, now terms such as 'complex interventions' and the 'cluster randomized controlled trial' are hot topics for discussion. The challenges involved in carrying out such studies are rarely presented. In this paper we discuss some of these challenges in relation to ethical and statistical considerations, and illustrate them using a recently completed cluster randomized controlled trial of a decision tool for early labour.

Association between women's self-diagnosis of labor and labor duration after admission

AIMS

To examine the association between women's perception of onset and the duration of labor after hospital admission.

METHODS

Women whose labor started spontaneously at term, delivering at the Hannover Medical School Hospital, Germany, between 2001 and 2004 were asked when and how labor had started. Answers were analyzed using structured content analysis. Women's symptoms were grouped in eight predefined categories; inter-rater agreement was assessed (kappa=0.93). Associations between women's symptoms and labor duration after admission were also analyzed.

RESULTS

Duration of labor after admission was longer in nulliparas (n=347) than in multiparas (n=304, P<0.001). Nulliparas experienced shorter labor in association with recurrent pain, advanced cervical dilatation at admission and spontaneous rupture of membranes. Oxytocin augmentation and epidural analgesia were associated with a longer duration. In multiparas, advanced cervical dilatation at admission, spontaneously ruptured membranes, blood-tinged mucus or emotional upheaval perceived by women were associated with a shorter interval from admission until birth.

CONCLUSIONS

How women diagnose their onset of labor relates to some extent with labor duration after admission. Recognized symptoms and their association with labor duration differed between nulliparas and multiparas.

Effect of a collector bag for measurement of postpartum blood loss after vaginal delivery: cluster randomised trial in 13 European countries

OBJECTIVE

To evaluate the effectiveness of the systematic use of a transparent plastic collector bag to measure postpartum blood loss after vaginal delivery in reducing the incidence of severe postpartum haemorrhage.

DESIGN

Cluster randomised trial.

SETTING

13 European countries.

PARTICIPANTS

78 maternity units and 25 381 women who had a vaginal delivery.

INTERVENTIONS

Maternity units were randomly assigned to systematic use of a collector bag (intervention group) or to continue to visually assess postpartum blood loss after vaginal delivery (control group).

MAIN OUTCOME MEASURES

The primary outcome was the incidence of severe postpartum haemorrhage in vaginal deliveries, defined as a composite of one or more of blood transfusion, intravenous plasma expansion, arterial embolisation, surgical procedure, admission to an intensive care unit, treatment with recombinant factor VII, and death.

RESULTS

Severe postpartum haemorrhage occurred in 189 of 11 037 of vaginal deliveries (1.71%) in the intervention group compared with 295 of 14 344 in the control group (2.06%). The difference was not statistically significant either in individual level analysis (adjusted odds ratio 0.82, 95% confidence interval 0.26 to 2.53) or in cluster level analysis (difference in weighted mean rate adjusted for baseline rate 0.16%, 95% confidence interval -0.69% to 1.02%).

CONCLUSION

Compared with visual estimation of postpartum blood loss the use of a collector bag after vaginal delivery did not reduce the rate of severe postpartum haemorrhage.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN66197422.

Roundtable discussion: Early labor: what's the problem?

In places where hospital birth is the norm, one of the major contemporary challenges to the organization of intrapartum care is posed by women who are not in established labor. In the United Kingdom, these women have been given a special name, "Category X," and they can account for a substantial percentage of admissions (1). These women are not deemed to be in need of hospital care, but the women themselves may feel otherwise as they struggle to understand the sensations they are experiencing. Until relatively recently, little research effort was expended on early and latent phase labor, reflecting, perhaps, the assumption that it is just a gentle and relatively straightforward preamble to the "real thing" that can easily be dealt with by keeping mobile, leaning over furniture, or doing the ironing. Because early labor is not seen as needing a health professional's input, the message is that it is unimportant. However, emerging evidence is challenging that view. Four large randomized controlled trials have recently evaluated interventions related to early labor care (2-5), stimulated by concerns that included repeated visits to the labor ward and the impact of early admission with the potential for a cascade of interventions. These trials, and other research reporting women's own perspectives on labor onset, reflect growing awareness that this stage of labor merits consideration in its own right. An International Early Labor Research Group has formed who will develop the evidence base in this important part of childbearing. The group represents varied disciplines including midwifery, psychology, epidemiology, antenatal education, and service user representatives. Members of this group are among those who have contributed to this Roundtable Discussion. The contributions draw attention to the complexities of early labor and its importance for childbearing women, their caregivers and companions. We might reasonably hypothesize that a woman's experience of early labor sets the scene for what follows, and it is clear that this is an area worthy of considerable further research.

Onset of labour: women's experiences and midwives' assessments in relation to first stage duration

AIM

The study aimed to assess the time of labour onset and its symptoms as perceived by women in labour and midwives, and the relationship between these and first stage duration.

METHODS

A longitudinal cohort study of women with a singleton pregnancy in cephalic presentation was performed in 41 maternity units. The sample comprised 1,170 women, 611 nulliparae (np) and 559 multiparae (mp), who answered two standardized questions on the onset of labour and selected the applicable symptoms of labour onset from a list of eight. A multivariate Cox regression model was computed covering further perinatal factors.

RESULTS

The median durations of the first stage of labour as assessed by the women themselves were 11 (np) and 6.5 h (mp), and as assessed by the midwives 7 (np) and 4 h (mp). Median time intervals between the start of labour onset symptoms as perceived by the women concerned and the midwives' diagnoses varied greatly: the shortest related to watery fluid loss (np = 1.5 h, mp = 0.0 h), the longest to alterations in sleep patterns (np = 11.5 h, mp = 4.5 h). Irregular pain, watery fluid loss and the time between self-diagnosed and professionally diagnosed onset of labour were just as closely associated with the duration of the first stage of labour as perinatal factors. Significant perinatal factors were induction with oxytocin, herbal remedies and PROM.

CONCLUSIONS

The perceptions of women in labour are as important as perinatal factors in determining the duration of the first stage of labour and should be taken into account in intrapartum care.