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

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.

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.

Hospital Admission in the Latent versus the Active Phase of Labor: Comparison of Perinatal Outcomes

Background: Admission in the latent phase of labor has been associated with increased risk of obstetric interventions compared to admission in the active phase. We aimed to investigate the relationship between labor phase at admission and obstetric and neonatal outcomes. Methods: A retrospective cohort study was conducted on 1005 women with uncomplicated singleton pregnancy admitted for spontaneous labor. Cesarean section rate and other perinatal outcomes were compared between women admitted in the latent phase and those admitted in the active phase. Results: Admission occurred in the active phase of labor for 331 women (32.9%) and in the latent phase for 674 (67.1%). Admission in the latent phase was more frequent in nulliparous than in multiparous (p < 0.01) and for Italian patients compared to foreigners. The incidence of caesarean section was similar between groups. Admission in the latent phase increased the likelihood of epidural analgesia (OR 3.47, 95% CI 1.96−6.14, in nulliparous, and OR 2.58, 95% CI 1.37−4.84, in multiparous) and increased the rate of augmentation of labor with oxytocin in multiparous (OR 2.87, 95% CI 1.05−7.85), without difference in neonatal outcomes. Conclusions: Admission in the latent phase is associated with more frequent use of epidural analgesia, without an increase in cesarean section or adverse neonatal outcomes.

Associations between cervical dilatation on admission and mode of delivery, a cohort study of Norwegian nulliparous women

OBJECTIVE

To investigate associations between cervical dilatation at hospital admission and mode of delivery.

METHODS

A cohort study with data from a cluster-randomised controlled trial, the Labour Progression Study. The study population of 6511 nulliparous women with a singleton fetus in cephalic presentation with spontaneous onset of labour at term, was divided into two groups: <4 cm and ≥ 4 cm cervical dilatation on admission. Binary logistic regression comparing mode of delivery was used to estimate crude and adjusted OR with associated 95% CI.

RESULTS

Of the total study population, 56.7% were admitted with < 4 cm cervical dilatation and 43.3% with ≥ 4 cm. Women admitted with ≥ 4 cm had a significantly higher chance of spontaneous delivery, with adjusted OR of 1.28 (95% CI: 1.14-1.44), and a significantly lower risk of caesarean sections, with an adjusted OR of 0.51 (95% CI: 0.41-0.64). For operative vaginal delivery, there were no significant difference between the study groups. Intrapartum interventions as epidural analgesia and augmentation with oxytocin were lower among women admitted with ≥ 4 cm cervical dilatation.

CONCLUSION

The study found a significantly higher chance of spontaneous delivery among women admitted with ≥ 4 cm. More research is needed to investigate why so many women are admitted early in labour, and how these women can be better cared for to increase their chances of a spontaneous delivery.

A survey exploring women's use of mobile apps in labour in the United Kingdom

OBJECTIVE

To examine women's use of mobile apps in labour in the United Kingdom.

DESIGN

Cross-sectional online survey. Descriptive analysis on women's reported use of apps whilst in labour, using multiple choice questions to explore frequency of app use and reasons and experiences of using apps. Thematic analysis of a free text question explored experiences and opinions regarding app use in labour.

SETTING

Social media. Two groups from Facebook.com and one group from Babycentre.co.uk PARTICIPANTS: A total of 749 women, surveyed over a one month period.

MEASUREMENTS

Demographics of women; characteristics of women's labours and birth; access to smartphones and app; rates of app use in labour and reasons for use; experiences of app use in labour.

FINDINGS

A total of 851 women responded, of which 749 were eligible. 431 (57.5%) reporting using an app in labour. No associations were found between age, ethnicity, education or mode of delivery and app use. Women who used an app were significantly more likely to have gone into labour spontaneously, and those who delivered between 40- 40+6 weeks gestation were significantly more likely to use an app. The majority of apps were used to monitor contractions, and most women found the apps useful and would recommend the apps they used. There was no association between number of labour ward attendances and app use, however women who used an app were significantly more likely to be admitted in more advanced labour. Qualitative comments found apps were viewed both as barriers and facilitators to the labour experience.

KEY CONCLUSIONS

A large number of women are using apps in labour, with potential benefits. There is no consensus from women on the experience of app use. The use of technology should not replace an individual assessment on a laboring women however. Although national bodies support the use of apps in maternity, there is currently insufficient evidence and regulation to support the safety and efficacy of these recommendations.

IMPLICATIONS FOR PRACTICE

Those working in maternity services should be aware many women are using apps in labour, and can consider this information as part of their assessment. Further work is needed to explore what women want from an app in labour, and to investigate whether app use can benefit a woman's experience of labour and improve outcomes.

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.

Labour admission assessment results of index pregnancy as predictors of intrapartum stillbirth in public health facilities of Addis Ababa: A case-control study

BACKGROUND

Approximately one-third of the global stillbirth burden occurs during intrapartum period. The ability to assess obstetric parameters including effacement, dilatation, uterine contraction, decent, rupture of the uterus, and moulding of the foetal head are among the essential competencies required by obstetric service providers admitting women for labour in health facilities. Misdiagnosis of these conditions could result in unnecessary obstetric interventions and unfavourable obstetric outcomes including intrapartum stillbirth. This study aimed to assess associations between missed diagnosis plus complication of labour on admission and intrapartum stillbirth.

METHODS

A case-control study using primary data from chart review of medical records of women who experienced intrapartum stillbirth in 20 public health centres and three public hospitals of Addis Ababa between 01 July 2010 and 30 June 2015 was conducted. Data were collected from charts of all cases meeting the inclusion criteria. Medical records of women with livebirths were randomly selected and reviewed from each public health facilities in two to one (2:1) control to case ratio. Accordingly, 728 cases of stillbirth out of 1,056 charts met the inclusion criteria whereas 1,551 controls out of 1,705 were also considered in the study.

RESULTS

Proportionally, more women in the stillbirth group (39.4%) than in the livebirth group (30.2%) experienced ruptured membrane on admission, with the difference being statistically significant (OR 1.7, 95% CI 1.37-2.03). Significantly higher proportion of women in the intrapartum stillbirth group experienced FRH lower than 110/min, a result suggestive of foetal distress on admission. Proportionally, more women in the intrapartum stillbirth group (14.5%) than in the livebirth group (4.5%) had breech foetal presentation on admission for labour, the difference being statistically significant (aOR 3.26 95% CI 1.93-5.50). Intrapartum stillbirth was slightly higher among women with cervical dilatation 4cm or more on admission (OR 1.2, 95% CI 1.00-1.45). This could be owing to delay in seeking obstetric care or misdiagnosis of the condition, a situation that seeks more rigorous study to determine the underlying causal links. Diagnosis of foetal member was missed among more cases than controls where the difference was statistically significant (aOR 1.51, CI 1.03-2.19).

CONCLUSION

Low FHR, non-vertex foetal presentations and ruptured cervical membrane were predictors of intrapartum stillbirth. Health facilities could avert unnecessary foetal loss by undertaking timely actions to manage obstetric emergencies on admission to labour.

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.

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

OBJECTIVE

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

DESIGN

Cross-sectional design with survey.

SETTING/LOCAL PROBLEM

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

PARTICIPANTS

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

INTERVENTION/MEASUREMENTS

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

RESULTS

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

CONCLUSION

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

Advanced cervical dilatation as a predictor for low emergency cesarean delivery: a comparison between migrant and non-migrant Primiparae - secondary analysis in Berlin, Germany

Background

Cesarean rates are higher in women admitted to labor ward during early stages rather than at later stages of labor. In a study in Germany, crude cesarean rates among Turkish and Lebanese immigrant women were low compared to non-immigrant women. We evaluated whether these immigrant women were admitted during later stages of labor, and if so, whether this explains their lower cesarean rates.

Methods

We enrolled 1413 nulliparous women with vertex pregnancies, singleton birth, and 37+ week of gestation, excluding elective cesarean deliveries, in three Berlin obstetric hospitals. We applied binary logistic regression to adjust for social and obstetric factors; and standardized coefficients to rank predictors derived from the regression model.

Results

At the time of admission to labor ward, a smaller proportion of Turkish migrant women was in the active phase of labor (cervical dilation: 4+ cm), compared to women of Lebanese origin and non-immigrant women. Rates of cesarean deliveries were lower in women of Turkish and Lebanese origin (15.8 and 13.9%) than in non-immigrant women (23.9%). In the logistic regression analysis, more advanced cervical dilatation was inversely associated with the outcome cesarean delivery (OR: 0.76, 95%CI: 0.70–0.82). In addition, higher maternal age (OR: 1.06, 95%CI: 1.04–1.09), application of oxytocic agents (OR: 0.55, 95%CI: 0.42–0.72), and obesity (OR: 2.25, 95%CI: 1.51–3.34) were associated with the outcome. Ranking of predictors indicate that cervical dilatation is the most relevant predictor derived from the regression model.

Conclusions

Advanced cervical dilatation at the time of admission to labor ward does not explain lower emergency cesarean delivery rates in Turkish and Lebanese migrant women, despite the fact that this is the strongest among the predictors for emergency cesarean delivery identified in this study.

Early labour experience questionnaire: Psychometric testing and women's experiences in a Swedish setting

OBJECTIVE

(a) to psychometrically test the Early Labour Experience Questionnaire (ELEQ) among both primi- and multiparous women giving birth in a Swedish setting, and (b) to describe and compare their experiences during early labour in relation to background characteristics.

DESIGN

a cross-sectional study.

SETTING

a county in Sweden.

PARTICIPANTS

primi- and multiparous women with a spontaneous onset of labour after gestational week 37 + 0. In total, n = 1193 women were invited, and n = 754 responded the questionnaire, with a final total of n = 344 primi and n = 410 multiparous women.

METHODS

the ELEQ was translated with cross-cultural adaptation. The validity was determined using exploratory factor analysis with principal axis factoring analyses. Reliability was estimated from the internal consistency using Cronbach's alpha. The relationship between the questionnaire and the demographic characteristics of the participating women were analysed using ANOVA and t-test.

FINDINGS

an explorative factor analysis showed a three-factor solution for primiparas women (SWE-ELEQ-PP) consist of 23 items and a stable factor structure that explained 49.2% of the total variance with sufficient reliability coefficients (0.81-0.86). A four-factor solution for multiparous women (SWE-ELEQ-MP) consist of 22 items, with 52.62% of the total variance explained and with adequate internal consistency reliability coefficients (0.77-0.86) for three factors and relatively low stability (0.62) for the fourth factor with two items. Primiparous women scored significantly higher on items about feeling confused, and significantly lower on some items measuring emotional wellbeing and perceptions of midwifery care compared to multiparous women. Primiparous women with longer early labour (>18 h), scored significantly lower on the perceptions of midwifery care. Primi- and multiparous women who were dissatisfied with their telephone conversation or with not being admitted during early labour, scored significantly lower on emotional wellbeing, higher regarding emotional distress, and significantly lower about perceptions of midwifery care.

KEY CONCLUSIONS

the SWE-ELEQ-PP and SWE-ELEQ-MP are considered valid questionnaires for use in a Swedish setting. Differences exist between parity and the factor structure and experiences in early labour vary. Women less content with early labour management decisions rated perceived midwifery care lower regardless of parity.

IMPLICATION FOR PRACTICE

the questionnaire can be used to evaluate early labour care in a Swedish setting. The result suggests that differences according to parity exist and should be addressed when managing early labour care and a more individualised approach requires considerations.

Accuracy of immediate antepartum ultrasound estimated fetal weight and its impact on mode of delivery and outcome - a cohort analysis

Background

The aim of the study was to investigate the accuracy of ultrasound-derived estimated fetal weight (EFW) and to determine its impact on management and outcome of delivery.

Methods

In this single-center cohort analysis, women with a singleton term pregnancy in the beginning stages of labor were included. Women with immediately antepartum EFW (N = 492) were compared to women without ultrasound (N = 515).

Results

EFW was correct (deviation from birth weight ≤ 10%) in 72.2% (355/492) of patients with fetal biometry; 19.7% (97/492) were underestimated, and 8.1% (40/492) were overestimated. Newborns with a lower birth weight were more frequently overestimated, and newborns with higher birth weight were more frequently underestimated. The mean difference between EFW and real birth weight was − 114.5 g (standard deviation ±313 g, 95% confidence interval 87.1–142.0). The rate of non-reassuring fetal heart tracing (9.8% vs. 1.9%, P < 0.001) and of caesarean delivery (9.1% vs. 5.0%, P = 0.013) was higher in women with EFW. Overestimation was associated with an increased risk for delivery by caesarean section (odds ratio 2.80; 95% confidence interval 1.2–6.5, P = 0.017). After adjustment, EFW remained associated with increased non-reassuring fetal heart tracing (odds ratio 4.73; 95% confidence interval 2.3–9.6) and caesarean delivery (odds ratio 1.86; 95% confidence interval 1.1–3.1). The incidence of perineal tears of grade 3/4, shoulder dystocia, postnatal depression and neonatal acidosis did not differ between groups.

Conclusions

Antepartum ultrasound-derived EFW does not improve maternal and fetal outcome and is therefore not recommended.