Continuous Support Promotes Obstetric Labor Progress and Vaginal Delivery in Primiparous Women - A Randomized Controlled Study

Quantifying the association between doula care and maternal and neonatal outcomes

BACKGROUND

The United States suffers from an increasing rate of severe maternal morbidity, paired with a wide disparity in maternal health by race. Doulas are posited to be a useful resource to increase positive outcomes and to decrease this disparity.

OBJECTIVE

This study aimed to evaluate the association between doula care and a broad range of maternal and neonatal outcomes in various subpopulations.

STUDY DESIGN

This was a retrospective cohort study of deliveries that were recorded from January 2021 to December 2022 at a single institution where they received prenatal care. The exposure was receipt of doula care prenatally and at delivery. We evaluated both the maternal (cesarean delivery, cesarean delivery of nulliparous, term, singleton, vertex infant, vaginal birth after cesarean, gestational hypertension, preeclampsia, postpartum emergency department visit, readmission, and attendance of postpartum office visit) and neonatal (neonatal intensive care unit admission, unexpected complications in term newborns, breastfeeding, preterm delivery, and intrauterine growth restriction) outcomes. Because our institution previously employed targeted outreach by offering doula services to patients at highest risk, we used multiple methods to generate an appropriate comparison population. We conducted a multivariate logistic regression and conditional regressions using propensity scores to model the likelihood of doula care to generate adjusted risk differences associated with doula care. Analyses were repeated in populations stratified by race (White vs Black) and then by payor status (public vs commercial).

RESULTS

Our cohort included 17,831 deliveries; 486 of those received doula care and 17,345 did not. Patients who received doula care were more likely to self-report Black race, be publicly insured, and to live in a more disadvantaged neighborhood. Regardless of the analytical approach, for every 100 patients who received doula care, there were 15 to 34 more vaginal births after cesarean (adjusted risk difference, 15.6; 95% confidence interval, 3.8-27.4; adjusted risk difference, 34.2; 95% confidence interval, 0.046-68.0) and 5 to 6 more patients who attended a postpartum office visit (adjusted risk difference, 5.4; 95% confidence interval, 1.4-9.5; adjusted risk difference, 6.8; 95% confidence interval, 3.7-9.9) when compared with those who did not receive doula services. Infants born to these patients were 20% more like likely to be exclusively breastfed (adjusted risk ratio, 1.22; 95% confidence interval, 1.07-1.38), and doula care was associated with 3 to 4 fewer preterm births (adjusted risk difference, -3.8; 95% confidence interval, -6.1 to -1.5; -4.0; 95% confidence interval, -6.2 to -1.8) for every 100 deliveries that received doula care. Results were consistent regardless of race or insurance. Results were also consistent when doula care was redefined as having at least 3 prenatal encounters with a doula.

CONCLUSION

Doula care was associated with more vaginal births after cesarean delivery, improved attendance of postpartum office visits, improved breastfeeding rates, and fewer preterm deliveries. The effect of doula care was consistent across race and insurance status.

A comparison of childbirth self-efficacy, fear of childbirth, and labor pain intensity between primiparas and multiparas during the latent phase of labor: a cross-sectional study

BACKGROUND

Childbirth is a long-lasting physiological stress. As one of the main stressors, labor pain exists throughout the whole process. Childbirth self-efficacy is the confidence, or belief that they can manage pain during childbirth. This sense of self-efficacy determines how pregnant women deal with labor pain and enables them to regulate their behavior and actively deal with childbirth. However, the difference in pain sensitivity between single births (primiparas) and multiple births (multiparas) has rarely been investigated.

OBJECTIVES

This study is aimed at investigating self-efficacy, fear of childbirth, labor pain of primiparas and multiparas and exploring factors related to the perceived labor pain intensity of pregnant women.

DESIGN

Prospective cross-sectional study.

SETTING(S)

Labour and delivery in a large academic specialized hospital in Guangzhou, China.

PARTICIPANTS

A total of 347 women, (182 primiparas and 165 multiparas) were enrolled in the data analysis. Pain was assessed before cervical dilatation (cervical dilatation ≤ 3 cm for the first delivery and ≤ 2 cm for the second delivery).

METHOD

The general information of participants was obtained by questionnaire and obstetrical records of the subjects were obtained from the electronic medical records extracted from the electronic medical record system (EMRS). Childbirth self-efficacy, fear of childbirth (FOC) and labor pain were compared between primiparas and multiparas. Paired t-test, chi-square test, Mann-Whitney test, univariate and multivariate regression analysis were used to analyze labor pain between the two groups and investigate factors related perceived labor pain intensity.

RESULTS

The total scores related to fear of childbirth, fetal health, self-control, and labor pain injury of multiparas were notably reduced compared with primiparas (all P < 0.05). The perceived labor pain intensity and duration of the first stage of labor was reduced in the multipara group compared with the primipara group. The childbirth control sense of the multipara was better than that of the primipara. The perceived labor pain intensity was negatively correlated with advanced age (age ≥ 35 years), self-efficacy score, family support, and education (all P < 0.05). In contrast, the perceived labor pain intensity was positively correlated with tension, severe fear of childbirth, and anxiety (P < 0.05). Self-efficacy, gravidity, delivery cognition, and fear of childbirth were independent risk factors for the perceived labor pain intensity in the latent period (all P < 0.05).

CONCLUSIONS

Fear of childbirth is a predictor of perceived labor pain intensity. The extent of labor pain (minimum and maximum) can be predicted by the level of fear the expectant mother has. During the latent phase of labor, self-efficacy, fear of childbirth and labor pain are different between primiparas and multiparas.

Status of the midwifery workforce and childbirth services and the impact of midwife staffing on birth outcomes in China: a multicentre cross-sectional study

OBJECTIVE

To investigate the status of the midwifery workforce and childbirth services in China and to identify the association between midwife staffing and childbirth outcomes.

DESIGN

A descriptive, multicentre cross-sectional survey.

SETTING

Maternity hospitals from the eastern, central and western regions of China.

PARTICIPANTS

Stratified sampling of maternity hospitals between 1 July and 31 December 2021.The sample hospitals received a package of questionnaires, and the head midwives from the participating hospitals were invited to fill in the questionnaires.

RESULTS

A total of 180 hospitals were selected and investigated, staffed with 4159 midwives, 412 obstetric nurses and 1007 obstetricians at the labour and delivery units. The average efficiency index of annual midwifery services was 272 deliveries per midwife. In the sample hospitals, 44.9% of women had a caesarean delivery and 21.4% had an episiotomy. Improved midwife staffing was associated with reduced rates of instrumental vaginal delivery (adjusted β -0.032, 95% CI -0.115 to -0.012, p<0.05) and episiotomy (adjusted β -0.171, 95% CI -0.190 to -0.056, p<0.001).

CONCLUSION

The rates of childbirth interventions including the overall caesarean section in China and the episiotomy rate, especially in the central region, remain relatively high. Improved midwife staffing was associated with reduced rates of instrumental vaginal delivery and episiotomy, indicating that further investments in the midwifery workforce could produce better childbirth outcomes.

Relationships Among Individual and Hospital Characteristics and Self-Efficacy in Labor Support Among Intrapartum Nurses in Texas

OBJECTIVE

To explore the relationships among individual and workplace characteristics and self-efficacy in labor support among intrapartum nurses.

DESIGN

Cross-sectional survey.

SETTING

Online distribution from April to August 2020.

PARTICIPANTS

Members of the Texas section of the Association for Women's Health, Obstetric, and Neonatal Nurses (N = 106).

METHODS

I conducted descriptive analysis on individual and workplace characteristics, including scores on the Self-Efficacy Labor Support Scale. I conducted backward stepwise multivariate linear regression to assess the factors associated with self-efficacy in providing labor support.

RESULTS

Years as an intrapartum nurse had a positive association with self-efficacy in labor support. Experience with open-glottis pushing, the overall cesarean birth rate, and the use of upright positioning during labor and birth were also positively associated with self-efficacy in labor support. Conversely, lack of recognition by providers was negatively associated with self-efficacy in labor support.

CONCLUSION

Findings suggest that modifiable factors at the individual and hospital levels are associated with nurses' self-efficacy in labor support. Hospitals must work to engage in obstetric practices that are congruent with providing labor support, including the use of experienced nurses to mentor new nurses and the creation of a unit culture to reinforce the intent of individual nurses to provide labor support.

What is 'physiological birth'? A scoping review of the perspectives of women and care providers

PROBLEM

Physiological birth was defined by the World Health Organization in 1997, however, clinical practices in childbirth have changed considerably since this time.

BACKGROUND

Ambiguous terms in healthcare such as 'physiological birth' may cause confusion amongst care providers and consumers.

AIM

To identify what is known about physiological birth, and how perceptions of physiological birth manifest in current literature.

METHODS

This review followed the Joanna Briggs Institute methodology for scoping reviews and the PRISMA-ScR checklist. Four databases were searched using keywords relating to physiological birth. Relevant studies were identified using agreed criteria, and data were extracted and synthesised.

RESULTS

A total of 24 studies met the inclusion criteria for this review. Three connected factors were identified: (1) Physiological birth in a risk-averse system, (2) Dominant voices in birth, and (3) Lack of exposure to physiological birth. No unified universal definition of physiological birth was identified in the literature.

DISCUSSION

'Physiological birth' as a term lacks consistency. A risk-averse healthcare system could be a barrier to physiological birth. Dominant voices in the birthing space can dictate the way birth occurs. Lack of exposure to physiological birth may diminish the acquisition and maintenance of important skills and knowledge among care providers. Recognising the factors important to women could lead to a positive birth experience.

CONCLUSION

Excluding a woman's subjective experience from health professionals' understanding of physiological birth increases the likelihood of risk management being the paramount objective in clinical decision-making. We propose it is timely to align clinical understanding of physiological birth with midwifery's woman-centred professional philosophy.

Non-Pharmacological Pain Management in Labor: A Systematic Review

Childbirth is a remarkable, life-changing process and is frequently regarded as an excruciating, physically and emotionally demanding experience that women endure. Labor pain management poses a significant challenge for obstetricians and expectant mothers. Although pharmacological pain management is the gold standard, it still imposes risks on the mother and baby. Recently, non-pharmacological pain management (NPPM) has emerged as a safe, effective option. Six databases were searched for articles published up to 2023 using specific related keywords and defined inclusion and exclusion criteria. The extraction and gathering of data was made so as to be categorized into physical, psychological, and complementary NPPM techniques. In light of the enormous development and diversity of NPPM techniques, the present review aims to examine contemporary NPPM knowledge and application, discussing efficacy, advantages, limitations, and potential adverse effects, with a specific focus on women's individual requirements, to strengthen obstetricians' knowledge in guiding decision-making for women in childbirth.

A survey of Australian midwives: Experts in nitrous oxide administration within the peripartum setting

PROBLEM

There is little documented evidence of midwives' perspectives regarding the use of nitrous oxide in the peripartum period.

BACKGROUND

Nitrous oxide is an inhaled gas used widely in the peripartum period; usually offered and managed by midwives.

AIM

Explore midwives' knowledge, perceptions, and practices of facilitating women's use of nitrous oxide in the peripartum period.

METHODS

An exploratory cross-sectional survey design was used. Quantitative data were analysed using descriptive and inferential statistics; open-ended responses underwent template analysis.

FINDINGS

Midwives (n = 121) working in three Australian settings reported regularly recommending the use of nitrous oxide and high levels of knowledge and confidence supporting its use. There was a significant association between midwifery experience, and perspectives on women's capacity to use nitrous effectively (p = 0.004); and desire for refresher education (p < 0.001). Midwives working in continuity models were more likely to support women using nitrous oxide in any situation (p = 0.039).

DISCUSSION

Midwives demonstrated expertise in facilitating nitrous oxide use, citing utility to relieve anxiety and distract women from pain or discomfort. Nitrous oxide was identified as an important adjunct to the provision of supportive care requiring midwifery therapeutic presence.

CONCLUSION

This study provides novel insight into midwives' support of nitrous oxide use in the peripartum setting revealing high levels of knowledge and confidence. Recognition of this unique expertise held by midwives is important to ensure transfer and development of professional knowledge and skills and emphasises the need for midwifery leadership in clinical service provision, planning and policy.

Emotional factors, medical interventions and mode of birth among low-risk primiparous women in Poland

Background and objectives

Birth is a critical event in women's lives. Since humans have evolved to give birth in the context of social support, not having it in modern settings might lead to more complications during birth. Our aim was to model how emotional factors and medical interventions related to birth outcomes in hospital settings in Poland, where c-section rates have doubled in the last decade.

Methodology

We analysed data from 2363 low-risk primiparous women who went into labor with the intention of giving birth vaginally. We used a model comparison approach to examine the relationship between emotional and medical variables and birth outcome (vaginal or c-section), including sociodemographic control variables in all models.

Results

A model with emotional factors better explained the data than a control model (ΔAIC = 470.8); women with continuous personal support during labor had lower odds of a c-section compared to those attended by hospital staff only (OR = 0.12, 95% CI = 0.09 - 0.16). A model that included medical interventions also better explained the data than a control model (ΔAIC = 133.6); women given epidurals, in particular, had increased odds of a c-section over those who were not (OR = 3.55, 95% CI = 2.95 - 4.27). The best model included variables for both the level of personal support and the use of epidural (ΔAIC = 598.0).

Conclusions and implications

Continuous personal support during childbirth may be an evolutionarily informed strategy for reducing complications, including one of the most common obstetrical complications in modern hospital settings, the c-section.

The clinical characteristics of perineal tears: A study carried out on 14 pregnant women in a tertiary center: Case series

Background

The sheer quality of the female genital tract is not always respected at the time of childbirth because no protocol for the management of perineal tears exists in our services these days. The management remains dependent on a gynecologist and obstetrician. The study aimed to describe the characteristics of perineal tears.

Methods

Our cross-sectional, retrospective, and descriptive study focused on patients admitted for childbirth and hospitalized in the obstetrics department of the Saint Luc Tertiary Clinic for a period from March 2021 to March 2022. During this period, we recorded 111 deliveries with 14 perineal tears.

Results

A total of 111 deliveries were recorded with a 12.6% frequency of perineal tears. 64.3% of women aged between 26 and 35 and 71.4% of primiparous women were affected by perineal tears. For delivery, 64.3% of births were eutocic deliveries, with 42.9% of children born with a birth weight greater than 4 kg, and the cephalic presentation delivered 86% of children. For degrees of perineal tears, 64.3% of patients had first-degree perineal tears. For postpartum treatment of perineal tears, analgesics help calm the pain, and antibiotic therapy has been considered. For fourth and third-degree tears, episiotomy was performed as a surgical procedure.

Conclusion

Perineal tears are the trauma often encountered in obstetrics; the first few suffer from it essentially. The high birth weight of children is often the cause. They require immediate management to prevent or avoid infections.

•

Women have a very complex anatomy, hence the high risk of trauma or tears of the perineum that are often unavoidable during childbirth. Young primiparous women are the most vulnerable to perineal tears with a very high prevalence.

•

The high weight and cephalic presentation of children at delivery are the factors causing perineal tears in women. Vaginal delivery and the number of foetuses has an impact on the integrity of the perineum.

•

During childbirth, perineal tears should be brought to the attention of obstetric providers to avoid complications for the woman.

Use and Effects of Augmentation of Labor with Oxytocin: A Single-Center, Retrospective, Case-Control Study of 4350 Women in Warsaw, Poland, 2015-2020

BACKGROUND Although there have been some recent clinical trials on the effects of augmentation of labor with oxytocin, or augmentation of labor, there are no clinical guidelines to explain the variations in obstetric practice between countries and within countries. This retrospective case-control study from a single center in Warsaw, Poland aimed to evaluate the use and effects of augmentation of labor with oxytocin in 4350 women between 2015 and 2020. MATERIAL AND METHODS This was a single-center, retrospective, case-control study in which 29 455 cases were qualified for analysis. The study included the analysis of 2 groups: the study group consisted of 4382 patients who underwent stimulation of childbirth, and the control group consisted of 25 073 patients who did not undergo this obstetric procedure. RESULTS Multivariate logistic regression analysis showed that the factors increasing the frequency of augmentation of labor were higher BMI (P<0.05), preinduction (P<0.05), epidural anesthesia (P<0.05), and family present at birth (P<0.05). Factors influencing reduction in the frequency of augmentation of labor were higher number of deliveries (P<0.05), vaginal birth after cesarean (P<0.05), and pre-pregnancy hypertension (P<0.05). CONCLUSIONS This study from a single center in Poland showed that BMI, preinduction, epidural anesthesia, and family present at birth significantly increased the frequency of labor stimulation with oxytocin. However, a history of previous pregnancies, previous cesarean sections, and pre-pregnancy hypertension significantly reduced the frequency of augmentation of labor with oxytocin.

Birth, love, and fear: Physiological networks from pregnancy to parenthood

Pregnancy and childbirth are among the most dramatic physiological and emotional transformations of a lifetime. Despite their central importance to human survival, many gaps remain in our understanding of the temporal progression of and mechanisms underlying the transition to new parenthood. The goal of this paper is to outline the physiological and emotional development of the maternal-infant dyad from late pregnancy to the postpartum period, and to provide a framework to investigate this development using non-invasive timeseries. We focus on the interaction among neuroendocrine, emotional, and autonomic outputs in the context of late pregnancy, parturition, and post-partum. We then propose that coupled dynamics in these outputs can be leveraged to map both physiologic and pathologic pregnancy, parturition, and parenthood. This approach could address gaps in our knowledge and enable early detection or prediction of problems, with both personalized depth and broad population scale.

The concept, importance and values of support during childbearing and breastfeeding - A discourse paper

BACKGROUND

Professional support in childbearing has beneficial effects on childbirth experience, interactions within the family, breastfeeding and medical outcomes. However, more knowledge is needed about prerequisites for professional support to be valuable and satisfactory during childbearing.

AIM

The aim of this discourse paper is to describe and explore prerequisites for professional support that are of value for women and their families during childbearing as well as how healthcare organizations can be formed to facilitate these prerequisites.

DESIGN

Discourse paper.

METHODS

This discourse paper is based on our own experiences and is supported by literature and theory.

RESULTS

Well-functioning structures and processes facilitate professional support that leads to safe, secure, calm and prepared parents with the ability to handle the challenges of childbearing and parenting. When organizing care in childbearing, prerequisites for support needs must also be considered.

Content validity of the nursing diagnosis powerlessness in women during natural childbirth

OBJECTIVE

To validate the content of the nursing diagnosis powerlessness in women during natural childbirth.

METHOD

A nursing diagnosis content validation, in which 29 experts analyzed the definition of powerlessness and assessed the relevance of related factors, populations at risk, associated conditions and defining characteristics. These elements were considered relevant when the Content Validity Index was greater than or equal to 0.9.

RESULTS

Experts considered the definition resulting from the concept analysis more appropriate for the diagnosis under study. Regarding the assessment of diagnostic elements, 10 related factors, two populations at risk, three associated conditions and 10 defining characteristics were considered relevant.

CONCLUSION

The new definition for powerlessness and 25 elements have been validated by experts. These can support the operationalization of the Nursing Process for parturient women.