Factors influencing the fulfillment of women's preferences for birthing positions during second stage of labor

Practice Programme for Upright Positions in the Second Stage of Labour: the development of a complex intervention based on the Medical Research Council Framework

AIMS

This study aimed to develop a Practice Programme for Upright Positions in the Second Stage of Labour to provide a reference for midwifery professionals in the standardized implementation of upright positions in clinical practice.

BACKGROUND

The adoption of upright positions in the second stage of labour is recommended by many international organizations, but upright positions have not been widely used and their implementation varies greatly across studies.

METHODS

The Practice Programme for Upright Positions in the Second Stage of Labour was developed under the guidance of the Medical Research Council framework for developing and evaluating complex interventions and the World Health Organization handbook for guideline development. Four stages were conducted: (1) establishing the intervention development group; (2) identifying a theoretical basis and forming a content framework; (3) evidence retrieval and synthesis; (4) refining and modelling the practice programme.

RESULTS

The content framework of the Practice Programme for Upright Positions in the Second Stage of Labour was formed based on the literature review, semi- structured interviews and expert consultation, including indications and contraindications, implementation methods, observations, potential risks and precautions. According to each item, we conducted a series of systematic reviews, and summarized the available best evidence from clinical guidelines, systematic reviews and original studies. Eventually, the Practice Programme for Upright Positions in the Second Stage of Labour was developed, integrating the findings of the iterative evidence reviews and revised by stakeholders.

CONCLUSIONS

This study firstly reported the development process of the Practice Programme for Upright Positions in the Second Stage of Labour, characterized by evidence-based, iteratively-processed, and highly-rigorous. The implications may guide researchers to embed the intervention normatively into clinical practice for improving maternal and infant outcomes.

IMPLICATIONS FOR NURSING MANAGEMENT

Facilitate systematic labour position management, and guide midwives in the successful implementation of upright positions.

Barriers and facilitators to the implementation of a practice programme for upright positions in the second stage of labour in China: A qualitative study

OBJECTIVE

Upright positions in the second stage of labour are recommended by many labour and birth guidelines, but they have not been widely used in China and the implementation varies greatly. Given this, we developed a Practice Programme for Upright Positions in the Second Stage of Labour (UPSSL Programme). Whether the UPSSL Programme can be translated into action in the local context is a crucial issue that needs to be further explored. This study aimed to explore barriers and facilitators to the implementation of the UPSSL Programme in the Chinese context to facilitate the integration of evidence and routine clinical practice.

DESIGN

A descriptive qualitative design was adopted.

SETTING

The study was conducted in the maternity unit of a tertiary general hospital in China.

PARTICIPANTS

A purposeful sampling was used to recruit midwives, obstetricians and their leaders. Data were collected through semi-structured face-to-face interviews. The Consolidated Framework for Implementation Research was used to guide the development of interview guide and the analysis of qualitative data. The study was reported following the Standards for Reporting Qualitative Research.

FINDINGS

Twelve eligible participants were interviewed, including eight midwives, two obstetricians, the head nurse of the delivery room, and the head of the maternity unit. Eight barriers and 10 facilitators were identified by using the directed content analysis. The barriers to implementing the UPSSL Programme were professionals' concerns about the potential risks of the programme (relative advantage), higher complexity (complexity), placement method of upright positions presented without pictures (design quality & packaging), staff shortage (cost), limited understanding of parturients' needs (patient needs & resources), lack of a training protocol for professionals (available resources), professionals' limited knowledge and skills in the programme (knowledge & beliefs about the intervention), and lack of confidence in the successful implementation of the programme (self-efficacy).

KEY CONCLUSIONS

Participants expressed several barriers and facilitators to implementing the UPSSL Programme in clinical practice in the Chinese context.

IMPLICATIONS FOR PRACTICE

The findings provide a reference for the development of targeted implementation strategies that could promote the integration of evidence and routine clinical practice, and thus facilitate the normative application and promotion of upright positions in China.

Effect of Flexible Sacrum Position on Maternal and Neonatal Outcomes in Public Health Facilities, Amhara Regional State, Ethiopia: A Quasi-Experimental Study

Restricting women giving birth in health care facilities from choosing the most comfortable position during labor and birth is a global problem. This study was aimed to examine the effect of flexible sacrum birth positions on maternal and neonatal outcomes in public health facilities in Ethiopia's Amhara Region. A non-equivalent control group post-test-only design was employed at public health facilities from August to November 2019. A total of 1048 participants were enrolled and assigned to intervention or control groups based on their choice of birth position. Participants who preferred the flexible sacrum birth position received the intervention, while participants who preferred the supine birth position were placed in the control group. Data were collected using observational follow-up from admission to immediate postpartum period. Log binomial logistic regression considering as treated analysis was used. Of the total participants, 970 women gave birth vaginally, of whom 378 were from the intervention group, and 592 were from the control group. The intervention decreased the chance of perineal tear and poor Apgar score by 43 and 39%, respectively. The flexible sacrum position reduced the duration of the second stage of labor by a mean difference of 26 min. Maternal and newborn outcomes were better in the flexible sacrum position.

Benefits and risks of upright positions during the second stage of labour: An overview of systematic reviews

BACKGROUND

Upright positions during the second stage of labour are assumed to have many physiological advantages that may facilitate normal birth. Clarifying the underlying benefits and risks of upright positions plays an important role in the implementation of upright positions. The benefits and risks of upright positions during the second stage of labour have been explored in several systematic reviews, but the results are divergent.

OBJECTIVE

To summarize the evidence on the underlying benefits and risks of upright positions during the second stage of labour by searching available systematic reviews to explore the best evidence for clinical practice and decision making.

DESIGN

Overview of systematic reviews.

DATA SOURCES

We systematically searched five English databases and four Chinese databases from inception to 15th March 2020 for any published and ongoing systematic reviews.

REVIEW METHODS

Two reviewers independently evaluated the methodological and the reporting quality of the included systematic reviews using the AMSTAR 2 tool and the PRISMA checklist. A descriptive synthesis was used by reporting the results of the highest quality reviews.

RESULTS

Seven systematic reviews met the eligibility criteria, of which two Cochrane reviews had the highest methodological and reporting quality. In women without epidural analgesia, upright positions significantly reduced the rate of instrumental vaginal birth (moderate-quality evidence), shortened the second stage of labour (very low-quality evidence), reduced the rate of episiotomy (very low-quality evidence) and abnormal foetal heart rate patterns requiring intervention (very low-quality evidence), but significantly increased the risk of blood loss greater than 500 ml (moderate-quality evidence) and second-degree perineal trauma (low-quality evidence). However, no definite benefits or risks of upright positions were found in women with epidural analgesia based on the current evidence.

CONCLUSIONS

This overview demonstrates that upright positions have both benefits and risks but the quality of the current evidence is relatively low. It is necessary for the researchers to conduct robust studies to provide stronger evidence. In addition, upright positions are recommended to be used depending on women's preferences and labour progress, but should also be carefully monitored especially in women with epidural analgesia. Registration number: CRD42020175820.

Creating an Optimality Index - Netherlands: a validation study

BACKGROUND

At present, the maternity care system in the Netherlands is being reorganized into an integrated model of care, shifting the focus of midwives to include increasing numbers of births in hospital settings and clients with medium risk profiles. In light of these changes, it is useful for midwives to have a tool which may help them in reflecting upon care practices that promote physiological childbirth practices. The Optimality Index-US is an evidence based tool, designed to measure optimal perinatal care processes and outcomes. It has been validated for use in the United States (OI-US), United Kingdom (OI-UK) and Turkey (OI-TR). The objective of this study was to adapt the OI-US for the Dutch maternity care setting (OI-NL).

METHODS

Translation and back translation were applied to create the OI-NL. A panel of maternity care experts (n = 10) provided input for face validation items in the OI-NL. Assessment of inter-rater reliability and ease of use was also conducted. Following this, the OI-NL was used prospectively to collect data on 266 women who commenced intrapartum care under the responsibility of a midwife. Twice groups were compared, based on parity and on care-setting at birth. Mean scores between these groups, corrected for perinatal background factors were assessed for discriminant validity.

RESULTS

Face validity was established for OI-NL on the basis of expert input. Discriminant validity was confirmed by conducting multiple regressions analyses for parity (β = 6.21, P = 0.00) and for care-setting (β = 12.1, p = 0.00). Inter-rater reliability was 98%, with one item (Apgar score) sensitive to scoring differences.

CONCLUSION

OI-NL is a valid and reliable tool for use in the Dutch maternity care setting. In addition to its value for assessing evidence-based maternity care processes and outcomes, there is potential for use for learning and reflection. Against the backdrop of a changing maternity care system, and due to the specificity of its items OI-NL may be of value as a tool for detecting subtle changes indicative of escalating medicalization of childbirth in the Netherlands.

Malawi women's knowledge and use of labour and birthing positions: A cross-sectional descriptive survey

PROBLEM

Despite research evidence supporting use of upright birthing positions, most women give birth in supine position. Little is known about women's knowledge and use of labour and birthing positions. Specifically, there is a lack of evidence on Malawi women's knowledge and use of birthing positions, and this limits the possibility of improvement in childbirth practices.

AIM

To assess women's knowledge and use of different positions during labour and birthing.

METHODS

The study used a cross-sectional descriptive survey in a Malawi maternity unit where 373 low-risk postnatal women participated in face-to-face exit interviews, using a structured questionnaire. A descriptive analysis of the categorical variables was conducted to examine frequencies and percentages.

FINDINGS

The majority of women knew about walking (66.4%) and lateral (60.6%) as labour positions, whereas 99.2% knew about the supine as a birthing position. Half of the women (50%) walked during labour and the majority (91.4%) gave birth whilst in supine position. Midwives were the main source of information on positions used during childbirth.

DISCUSSION

Education about different birthing positions is needed for women who deliver at the maternity unit so that they can make informed decisions on their own options for childbirth. However, midwives must have the competence to encourage and assist women give birth in different positions, so professional development of midwives in childbirth positions is a priority.

CONCLUSION

Childbirth education should include information on the various labour and birthing positions. Midwives should be equipped with appropriate skills to help women use different positions during childbirth.

Mothers and midwives perceptions of birthing position and perineal trauma: An exploratory study

BACKGROUND

Studies have associated lithotomy position during childbirth with negative consequences and increased risk of perineal injuries.

AIMS

To identify prevalence rates of different birthing position and episiotomy and to explore the differences in perspectives of mothers and midwives about birthing positions and perineal trauma.

METHODS

A survey involving 110 mothers and 110 midwives at two hospitals. Participants were mothers who had a vaginal birth/perineal injury and midwives who attended births that resulted in perineal injuries. Perceptions of mothers and midwives were analysed. Pearson's chi-square test was used to measure association between birthing positions and perineal trauma.

FINDINGS

Mothers, n=94 (85%) and midwives, n=108 (98%) reported high rates of lithotomy position for birth. N=63 (57%) of mothers perceived lithotomy position as not being helpful for birth. In contrast, a similar number of midwives perceived lithotomy position as helpful, n=65 (59%). However, a high majority of mothers, n=106 (96%) and midwives, n=97 (88%) reported they would be willing to use alternative positions. Majority of mothers had an episiotomy, n=80 (73%) and n=76 (69%) reported they did not give their consent. N=59 (53%) reported they were not given local anaesthesia for an episiotomy. n=30 (27%) of midwives confirmed they performed an episiotomy without local anaesthesia.

CONCLUSION

Care is not based on current evidence and embedded practices, i.e. birthing in lithotomy position and routine episiotomies are commonly used. However, this survey did find a willingness to change, adapt practice and consider different birthing positions and this may lead to fewer episiotomies being performed.

Better perineal outcomes in sitting birthing position cannot be explained by changing from upright to supine position for performing an episiotomy

BACKGROUND

women who give birth in supine position are more likely to have an episiotomy than women who give birth in sitting position. A confounding effect may be that women in upright positions in second stage of labour are asked to lie down if a professional needs to perform an episiotomy. This prospective cohort study aimed to determine whether this factor can explain the lower rate of episiotomy in sitting compared to supine position.

METHODS

data from 1196 women who had a spontaneous, vaginal birth were analysed. Positions during second stage and at birth were carefully recorded. Three groups of birthing positions were compared in multivariable analyses: 1) horizontal during second stage and supine at birth (horizontal/supine), 2) horizontal and upright during second stage and supine at birth (various/supine), 3) sitting at birth regardless of the position in second stage. Logistic regression analysis was used to adjust for known risk factors for perineal damage.

FINDINGS

women in sitting position at birth compared to those in the horizontal/supine group had a lower episiotomy rate (adjusted OR 0.28;95%-CI 0.14-0.56) and a non-significant higher intact perineum rate (adjusted OR 1.40, 95% CI 0.96-2.04). Women in the various/supine group compared to the horizontal/supine group had a similar episiotomy rate (adjusted OR 1.12;95%-CI 0.69-1.83).

CONCLUSIONS

we did not confirm our hypothesis that more women in supine compared to sitting position have an episiotomy because women in upright position are asked to lie down if an episiotomy is necessary.

Intrapartum referral from primary to secondary care in the Netherlands: a retrospective cohort study on management of labor and outcomes

BACKGROUND

In the Dutch maternity care system, primary care midwives provide care to low-risk women and refer to obstetricians if risks or complications occur. We examined reasons for referral, management of labor, and maternal and neonatal outcomes among women who were referred during labor.

METHODS

In a retrospective cohort study, descriptive analyses were performed on data obtained from patient records. Six purposively chosen hospitals in The Netherlands participated in the study from June 2011 to February 2012. The study population included 600 pregnant women who were referred during labor from primary to secondary care.

MAIN OUTCOME MEASURES

Reasons for referral, interventions after referral, mode of delivery, and maternal and neonatal outcomes.

RESULTS

Of women who were referred during labor, three out of four women were referred for moderate risk indications: request for pain relief (30.5%), meconium-stained liquor (25.3%), failure to progress during first stage of labor (14.0%), and prolonged ruptured membranes without contractions (12.5%). Of all women, 65.7 percent had a spontaneous vaginal delivery and 59.7 percent received some kind of pain relief. Acute referral, meaning fetal distress, occurred in 5.5 percent. Of the newborns, 2.7 percent had an Apgar score of 7 or less after 5 minutes and 1.2 percent had an umbilical cord pH < 7.05. Postpartum complications occurred among 11.0 percent of women.

CONCLUSION

Women who are referred during labor have a high probability of spontaneous vaginal delivery. To improve continuity of care and satisfaction for this group of women, management of labor could be continued by trained primary care midwives.

The role of maternity care providers in promoting shared decision making regarding birthing positions during the second stage of labor

INTRODUCTION

Through the use of a variety of birthing positions during the second stage of labor, a woman can increase progress, improve outcomes, and have a positive birth experience. The role that a maternity care provider has in determining which position a woman uses during the second stage of labor has not been thoroughly explored. The purpose of this qualitative investigation was to explore how maternity care providers communicate with women during the second stage of labor regarding birthing position.

METHODS

A literature-informed framework was developed to conduct a process of deductive content analysis of communication patterns between nulliparous women and their maternity care providers during the second stage of labor. Literature discussing shared decision making, control, and predictors of positive birth experiences were reviewed to develop a coding framework. The framework included the following categories: listening to women, encouragement, information, offering choices, and style of support. Forty-one audiotapes of women and their maternity care providers during the second stage of labor were transcribed verbatim and analyzed.

RESULTS

Themes identified in the transcripts included all those in the analytic framework, plus 2 added categories of communication: empathy and interaction. Maternity care providers in this study enabled women to select various birthing positions using a dynamic process that moved between open, informative approaches and more closed, directive approaches, depending on the woman's needs and clinical condition. As clinical conditions unfolded, women became more actively involved in shared decision making regarding birthing positions, and maternity care providers found the right balance between being responsive to the woman's questions or directives.

DISCUSSION

Enabling shared decision making during birth is not a linear process using a single approach; it is dynamic process that requires a variety of approaches. Maternity care providers can support a woman to use different birthing positions during the second stage of labor by employing a flexible style that incorporates clinical assessment and the woman's responses.

The use of episiotomy in a low-risk population in the Netherlands: a secondary analysis

BACKGROUND

To examine the episiotomy incidence and determinants and outcomes associated with its use in primary care midwifery practices.

METHODS

Secondary analysis of two prospective cohort studies (n = 3,404).

RESULTS

The episiotomy incidence was 10.8 percent (20.9% for nulliparous and 6.3% for parous women). Episiotomy was associated with prolonged second stage of labor (adj. OR 12.09 [95% CI 6.0-24.2] for nulliparous and adj. OR 2.79 [1.7-4.6] for parous women) and hospital birth (adj. OR 1.75 [1.2-2.5] for parous women). Compared with episiotomy, perineal tears were associated with a lower rate of postpartum hemorrhage in parous women (adj. OR 0.58 [0.4-0.9]). Fewer women with perineal tears reported perineal discomfort (adj. OR 0.35 [0.2-0.6] for nulliparous and adj. OR 0.22 [0.1-0.3] for parous women). Among nulliparous women episiotomy was performed most frequently for prolonged second stage of labor (38.8%) and among parous women for history of episiotomy or prevention of major perineal trauma (21.1%).

CONCLUSIONS

The incidence of episiotomy is high compared with some low-risk settings in other Western countries. Episiotomy was associated with higher rates of adverse maternal outcomes. Restricted use of episiotomy is likely to be beneficial for women.