Continuous support for women during childbirth

BACKGROUND

Historically, women have been attended and supported by other women during labour. However, in hospitals worldwide, continuous support during labour has become the exception rather than the routine.

OBJECTIVES

Primary: to assess the effects of continuous, one-to-one intrapartum support compared with usual care. Secondary: to determine whether the effects of continuous support are influenced by: (1) routine practices and policies; (2) the provider's relationship to the hospital and to the woman; and (3) timing of onset.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2013).

SELECTION CRITERIA

All published and unpublished randomised controlled trials comparing continuous support during labour with usual care.

DATA COLLECTION AND ANALYSIS

We used standard methods of The Cochrane Collaboration Pregnancy and Childbirth Group. Two review authors independently evaluated methodological quality and extracted the data. We sought additional information from the trial authors. We used random-effects analyses for comparisons in which high heterogeneity was present, and we reported results using the average risk ratio (RR) for categorical data and mean difference (MD) for continuous data.

MAIN RESULTS

Twenty-two trials involving 15,288 women met inclusion criteria and provided usable outcome data. Results are of random-effects analyses, unless otherwise noted. Women allocated to continuous support were more likely to have a spontaneous vaginal birth (RR 1.08, 95% confidence interval (CI) 1.04 to 1.12) and less likely to have intrapartum analgesia (RR 0.90, 95% CI 0.84 to 0.96) or to report dissatisfaction (RR 0.69, 95% CI 0.59 to 0.79). In addition, their labours were shorter (MD -0.58 hours, 95% CI -0.85 to -0.31), they were less likely to have a caesarean (RR 0.78, 95% CI 0.67 to 0.91) or instrumental vaginal birth (fixed-effect, RR 0.90, 95% CI 0.85 to 0.96), regional analgesia (RR 0.93, 95% CI 0.88 to 0.99), or a baby with a low five-minute Apgar score (fixed-effect, RR 0.69, 95% CI 0.50 to 0.95). There was no apparent impact on other intrapartum interventions, maternal or neonatal complications, or breastfeeding. Subgroup analyses suggested that continuous support was most effective when the provider was neither part of the hospital staff nor the woman's social network, and in settings in which epidural analgesia was not routinely available. No conclusions could be drawn about the timing of onset of continuous support.

AUTHORS' CONCLUSIONS

Continuous support during labour has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labour and birth.

Antenatal care packages with reduced visits and perinatal mortality: a secondary analysis of the WHO antenatal care trial - Comentary: routine antenatal visits for healthy pregnant women do make a difference

The practice and timing of routine antenatal visits for healthy pregnant women, introduced arbitrarily and without evidence of effectiveness, have become entrenched in obstetric practice over the last century. In 2001 the large, cluster randomized WHO Antenatal Care Trial concluded that a goal-orientated package of antenatal care with reduced visits seemed not to affect maternal and perinatal outcomes. The reduced visit package has been implemented in several countries. The current re-analysis finds that the significantly increased perinatal mortality which occurred in the reduced visit package persists after adjustment for potential confounding factors. The WHO Antenatal Care Trial provided the first evidence from a randomized trial that the traditional high frequency of routine visits in the third trimester may well reduce perinatal mortality.

Cohort profile: The promotion of breastfeeding intervention trial (PROBIT)

The PROmotion of Breastfeeding Intervention Trial (PROBIT) is a multicentre, cluster-randomized controlled trial conducted in the Republic of Belarus, in which the experimental intervention was the promotion of increased breastfeeding duration and exclusivity, modelled on the Baby-friendly hospital initiative. Between June 1996 and December 1997, 17,046 mother-infant pairs were recruited during their postpartum hospital stay from 31 maternity hospitals, of which 16 hospitals and their affiliated polyclinics had been randomly assigned to the arm of PROBIT investigating the promotion of breastfeeding and 15 had been assigned to the control arm, in which breastfeeding practices and policies in effect at the time of randomization was continued. Of the mother-infant pairs originally recruited for the study, 16,492 (96.7%) were followed at regular intervals until the infants were 12 months of age (PROBIT I) for the outcomes of breastfeeding duration and exclusivity; gastrointestinal and respiratory infections; and atopic eczema. Subsequently, 13,889 (81.5%) of the children from these mother-infant pairs were followed-up at age 6.5 years (PROBIT II) for anthropometry, blood pressure (BP), behaviour, dental health, cognitive function, asthma and atopy outcomes, and 13,879 (81.4%) children were followed to the age of 11.5 years (PROBIT III) for anthropometry, body composition, BP, and the measurement of fasted glucose, insulin, adiponectin, insulin-like growth factor-I, and apolipoproteins. The trial registration number for Current Controlled Trials is ISRCTN37687716 and that for ClinicalTrials.gov is NCT01561612. Proposals for collaboration are welcome, and enquires about PROBIT should be made to an executive group of the study steering committee (M.S.K., R.M.M., and E.O.). More information, including information about how to access the trial data, data collection documents, and bibliography, is available at the trial website (http://www.bristol.ac.uk/social-community-medicine/projects/probit/).

Repeated hands-and-knees positioning during labour: a randomized pilot study

Background. Caesarean birth rates in North America continue to rise, in the absence of benefit for mothers and babies. One reason may be that hospitalized labouring women spend most of their labours in recumbent or semi-recumbent positions. Although hands-and-knees position has theoretical advantages, efforts to encourage its adoption in practice are severely hampered by the lack of compelling evidence that it is beneficial. Before a definitive, large scale trial, with spontaneous vaginal birth as the primary outcome, could be justified in terms of time, effort, and expense, several feasibility and acceptability questions had to be addressed. We aimed to enrol 60 women in a pilot study to assess feasibility and acceptability of the trial protocol, and to obtain estimates of treatment effects on method of birth and persistent back pain. Methods. We conducted a pilot study at two North American hospitals. In ten months of recruitment, 30 nulliparous women in labour at term were randomly allocated to either usual care (use of any position during labour except hands-and-knees) or to try hands-and-knees for 15 min every hour during labour. Data were collected about compliance, acceptability, persistent back pain, intrapartum interventions, and women's views of their experiences. Results. Although mean length of time from randomization to delivery was over 12 hours, only 9 of the 16 women allocated to repeated hands-and-knees used it more than twice. Two of the 14 in the usual care group used hands-and-knees once. Twenty-seven women had regional analgesia (15 in the hands-and-knees group and 12 in the usual care group). Eleven in the hands-and-knees group and 14 in the usual care group had spontaneous vaginal births. One woman (in the hands-and-knees group) had a vacuum extraction. Four women in the hands-and-knees group and none in the usual care group gave birth by caesarean section. Hourly back pain ratings were highly variable in both groups, covering the full range of possible scores. Given the low compliance with the hands-and-knees position, it was not possible to explore relationships between use of the position and persistent back pain scores. When asked to rate their overall satisfaction with their birth experiences, the hands-and-knees group's ratings tended to be lower than those in the usual care group, although 11 in the hands-and-knees group and 8 in the usual care group stated they would probably or definitely try the position in a subsequent labour. Conclusion. We concluded that we could not justify the time and expense associated with a definitive trial. However such a trial could be feasible with modifications to eligibility criteria and careful selection of suitable settings.

Understanding the moral nature of intrapartum nursing

OBJECTIVE

To explore how intrapartum nurses understand and negotiate their moral responsibilities toward women during childbirth.

DESIGN

Qualitative critical narrative.

SETTING

Labor and birth unit in an urban Canadian hospital.

PARTICIPANTS

Fourteen intrapartum registered nurses.

METHODS

Critical narrative analysis using a feminist ethics perspective.

RESULTS

Nurses understood their moral responsibilities to laboring women in a variety of ways depending on the nurses' personal and professional experiences, the people involved, and the context of care. Four themes were identified: organizing and coordinating care, responding to the unpredictable, recognizing limits of responsibilities to others, and negotiating care with women and families. A key factor influencing responses to women was the degree to which expectations related to birth were deemed to be reasonable and mutually agreed upon among nurses, physicians, women, and their families. Although nurses were able to identify contextual influences that constrained their ability to maintain effective relationships with women, the influence of their own values on the care they provided was less apparent. Nurses also described limits of their responsibilities for others, which departed from the idealized expectations often reflected in professional guidelines

CONCLUSION

These findings suggest a need to challenge assumptions related to the provision of choice and family centered care to create environments that can support and sustain understanding and trust between nurses and women giving birth. In addition, given the lack of shared understandings of what constitutes best care, there is a need to develop collaborative models of care that include the voices of women as a central component.

Continuous support for women during childbirth

BACKGROUND

Historically, women have been attended and supported by other women during labour. However, in hospitals worldwide, continuous support during labour has become the exception rather than the routine.

OBJECTIVES

Primary: to assess the effects of continuous, one-to-one intrapartum support compared with usual care. Secondary: to determine whether the effects of continuous support are influenced by: (1) routine practices and policies; (2) the provider's relationship to the hospital and to the woman; and (3) timing of onset.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2012).

SELECTION CRITERIA

All published and unpublished randomised controlled trials comparing continuous support during labour with usual care.

DATA COLLECTION AND ANALYSIS

We used standard methods of The Cochrane Collaboration Pregnancy and Childbirth Group. Two review authors independently evaluated methodological quality and extracted the data. We sought additional information from the trial authors. We used random-effects analyses for comparisons in which high heterogeneity was present, and we reported results using the average risk ratio (RR) for categorical data and mean difference (MD) for continuous data.

MAIN RESULTS

Twenty-two trials involving 15,288 women met inclusion criteria and provided usable outcome data. Results are of random-effects analyses, unless otherwise noted. Women allocated to continuous support were more likely to have a spontaneous vaginal birth (RR 1.08, 95% confidence interval (CI) 1.04 to 1.12) and less likely to have intrapartum analgesia (RR 0.90, 95% CI 0.84 to 0.96) or to report dissatisfaction (RR 0.69, 95% CI 0.59 to 0.79). In addition, their labours were shorter (MD -0.58 hours, 95% CI -0.85 to -0.31), they were less likely to have a caesarean (RR 0.78, 95% CI 0.67 to 0.91) or instrumental vaginal birth (fixed-effect, RR 0.90, 95% CI 0.85 to 0.96), regional analgesia (RR 0.93, 95% CI 0.88 to 0.99), or a baby with a low five-minute Apgar score (fixed-effect, RR 0.69, 95% CI 0.50 to 0.95). There was no apparent impact on other intrapartum interventions, maternal or neonatal complications, or breastfeeding. Subgroup analyses suggested that continuous support was most effective when the provider was neither part of the hospital staff nor the woman's social network, and in settings in which epidural analgesia was not routinely available. No conclusions could be drawn about the timing of onset of continuous support.

AUTHORS' CONCLUSIONS

Continuous support during labour has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labour and birth.

Alternative versus conventional institutional settings for birth

BACKGROUND

Alternative institutional settings have been established for the care of pregnant women who prefer little or no medical intervention. The settings may offer care throughout pregnancy and birth, or only during labour; they may be part of hospitals or freestanding entities. Specially designed labour rooms include bedroom-like rooms, ambient rooms, and Snoezelen rooms.

OBJECTIVES

Primary: to assess the effects of care in an alternative institutional birth environment compared to care in a conventional setting. Secondary: to determine if the effects of birth settings are influenced by staffing, architectural features, organizational models or geographical location.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 March 2012).

SELECTION CRITERIA

All randomized or quasi-randomized controlled trials which compared the effects of an alternative institutional birth setting to a conventional setting.

DATA COLLECTION AND ANALYSIS

We used the standard methods of the Cochrane Collaboration Pregnancy and Childbirth Group. Two review authors evaluated methodological quality. We performed double data extraction and presented results using risk ratios (RR) and 95% confidence intervals (CI).

MAIN RESULTS

Ten trials involving 11,795 women met the inclusion criteria. We found no trials of freestanding birth centres or Snoezelen rooms. Allocation to an alternative setting increased the likelihood of: no intrapartum analgesia/anesthesia (six trials, n = 8953; RR 1.18, 95% CI 1.05 to 1.33); spontaneous vaginal birth (eight trials; n = 11,202; RR 1.03, 95% CI 1.01 to 1.05); breastfeeding at six to eight weeks (one trial, n = 1147; RR 1.04, 95% CI 1.02 to 1.06); and very positive views of care (two trials, n = 1207; RR 1.96, 95% CI 1.78 to 2.15). Allocation to an alternative setting decreased the likelihood of epidural analgesia (eight trials, n = 10.931; RR 0.80, 95% CI 0.74 to 0.87); oxytocin augmentation of labour (eight trials, n = 11,131; RR 0.77, 95% CI 0.67 to 0.88); instrumental vaginal birth (eight trials, n = 11,202; RR 0.89, 95% CI 0.79 to 0.99), and episiotomy (eight trials, n = 11,055; RR 0.83, 95% CI 0.77 to 0.90). There was no apparent effect on other adverse maternal or neonatal outcomes. Care by the same or separate staff had no apparent effects. No conclusions could be drawn regarding the effects of continuity of caregiver or architectural characteristics. In several of the trials included in this review, the design features of the alternative setting were confounded by important differences in the organizational models for care (separate staff for the alternative setting, offering more continuity of caregiver), and thus it is difficult to draw inferences about the independent effects of the physical birth environment.

AUTHORS' CONCLUSIONS

Hospital birth centres are associated with lower rates of medical interventions during labour and birth and higher levels of satisfaction, without increasing risk to mothers or babies.

Mind-body interventions during pregnancy for preventing or treating women's anxiety

BACKGROUND

Anxiety during pregnancy is a common problem. Anxiety and stress could have consequences on the course of the pregnancy and the later development of the child. Anxiety responds well to treatments such as cognitive behavioral therapy and/or medication. Non-pharmacological interventions such as mind-body interventions, known to decrease anxiety in several clinical situations, might be offered for treating and preventing anxiety during pregnancy.

OBJECTIVES

To assess the benefits of mind-body interventions during pregnancy in preventing or treating women's anxiety and in influencing perinatal outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2010), MEDLINE (1950 to 30 November 2010), EMBASE (1974 to 30 November 2010), the National Center for Complementary and Alternative Medicine (NCCAM) (1 December 2010), ClinicalTrials.gov (December 2010) and Current Controlled Trials (1 December 2010), searched the reference lists of selected studies and contacted professionals and authors in the field.

SELECTION CRITERIA

Randomized controlled trials, involving pregnant women of any age at any time from conception to one month after birth, comparing mind-body interventions with a control group. Mind-body interventions include: autogenic training, biofeedback, hypnotherapy, imagery, meditation, prayer, auto-suggestion, tai-chi and yoga. Control group includes: standard care, other pharmacological or non-pharmacological interventions, other types of mind-body interventions or no treatment at all.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion all assessed risk of bias for each included study. We extracted data independently using an agreed form and checked it for accuracy.

MAIN RESULTS

We included eight trials (556 participants), evaluating hypnotherapy (one trial), imagery (five trials), autogenic training (one trial) and yoga (one trial). Due to the small number of studies per intervention and to the diversity of outcome measurements, we performed no meta-analysis, and have reported results individually for each study. Compared with usual care, in one study (133 women), imagery may have a positive effect on anxiety during labor decreasing anxiety at the early and middle stages of labor (MD -1.46; 95% CI -2.43 to -0.49; one study, 133 women) and (MD -1.24; 95% CI -2.18 to -0.30). Another study showed that imagery had a positive effect on anxiety and depression in the immediate postpartum period. Autogenic training might be effective for decreasing women's anxiety before delivering.

AUTHORS' CONCLUSIONS

Mind-body interventions might benefit women's anxiety during pregnancy. Based on individual studies, there is some but no strong evidence for the effectiveness of mind-body interventions for the management of anxiety during pregnancy. The main limitations of the studies were the lack of blinding and insufficient details on the methods used for randomization.

Continuous support for women during childbirth

BACKGROUND

Historically, women have been attended and supported by other women during labour. However in hospitals worldwide, continuous support during labour has become the exception rather than the routine.

OBJECTIVES

Primary: to assess the effects of continuous, one-to-one intrapartum support compared with usual care. Secondary: to determine whether the effects of continuous support are influenced by: (1) routine practices and policies; (2) the provider's relationship to the hospital and to the woman; and (3) timing of onset.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2010).

SELECTION CRITERIA

All published and unpublished randomized controlled trials comparing continuous support during labour with usual care.

DATA COLLECTION AND ANALYSIS

We used standard methods of the Cochrane Collaboration Pregnancy and Childbirth Group. Two authors independently evaluated methodological quality and extracted the data. We sought additional information from the trial authors. We used random-effects analyses for comparisons in which high heterogeneity was present, and we reported results using the risk ratio for categorical data and mean difference for continuous data.

MAIN RESULTS

Twenty-one trials involving 15061 women met inclusion criteria and provided usable outcome data. Results are of random-effects analyses, unless otherwise noted. Women allocated to continuous support were more likely to have a spontaneous vaginal birth (RR 1.08, 95% CI 1.04 to 1.12) and less likely to have intrapartum analgesia (RR 0.90, 95% CI 0.84 to 0.97) or to report dissatisfaction (RR 0.69, 95% CI 0.59 to 0.79). In addition their labours were shorter (mean difference -0.58 hours, 95% CI -0.86 to -0.30), they were less likely to have a caesarean (RR 0.79, 95% CI 0.67 to 0.92) or instrumental vaginal birth (fixed-effect, RR 0.90, 95% CI 0.84 to 0.96), regional analgesia (RR 0.93, 95% CI 0.88 to 0.99), or a baby with a low 5-minute Apgar score (fixed-effect, RR 0.70, 95% CI 0.50 to 0.96). There was no apparent impact on other intrapartum interventions, maternal or neonatal complications, or on breastfeeding. Subgroup analyses suggested that continuous support was most effective when provided by a woman who was neither part of the hospital staff nor the woman's social network, and in settings in which epidural analgesia was not routinely available. No conclusions could be drawn about the timing of onset of continuous support.

AUTHORS' CONCLUSIONS

Continuous support during labour has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labour and birth.

Alternative versus conventional institutional settings for birth

BACKGROUND

Alternative institutional settings have been established for the care of pregnant women who prefer and require little or no medical intervention. The settings may offer care throughout pregnancy and birth, or only during labour; they may be part of hospitals or freestanding entities. Specially designed labour rooms include bedroom-like rooms, ambient rooms, and Snoezelen rooms.

OBJECTIVES

Primary: to assess the effects of care in an alternative institutional birth environment compared to care in a conventional institutional setting. Secondary: to determine if the effects of birth settings are influenced by staffing, architectural features, organizational models or geographical location.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2010).

SELECTION CRITERIA

All randomized or quasi-randomized controlled trials which compared the effects of an alternative institutional maternity care setting to conventional hospital care.

DATA COLLECTION AND ANALYSIS

We used standard methods of the Cochrane Collaboration Pregnancy and Childbirth Group. Two review authors evaluated methodological quality. We performed double data entry and have presented results using risk ratios (RR) and 95% confidence intervals (CI).

MAIN RESULTS

Nine trials involving 10684 women met the inclusion criteria. We found no trials of freestanding birth centres or Snoezelen rooms. Allocation to an alternative setting increased the likelihood of: no intrapartum analgesia/anaesthesia (five trials, n = 7842; RR 1.17, 95% CI 1.01 to 1.35); spontaneous vaginal birth (eight trials; n = 10,218; RR 1.04, 95% CI 1.02 to 1.06); breastfeeding at six to eight weeks (one trial, n = 1147; RR 1.04, 95% CI 1.02 to 1.06); and very positive views of care (two trials, n = 1207; RR 1.96, 95% CI 1.78 to 2.15). Allocation to an alternative setting decreased the likelihood of epidural analgesia (seven trials, n = 9820; RR 0.82, 95% CI 0.75 to 0.89); oxytocin augmentation of labour (seven trials, n = 10,020; RR 0.78, 95% CI 0.66 to 0.91); and episiotomy (seven trials, n = 9944; RR 0.83, 95% CI 0.77 to 0.90). There was no apparent effect on serious perinatal or maternal morbidity/mortality, other adverse neonatal outcomes, or postpartum hemorrhage. No firm conclusions could be drawn regarding the effects of variations in staffing, organizational models, or architectural characteristics of the alternative settings.

AUTHORS' CONCLUSIONS

When compared to conventional settings, hospital-based alternative birth settings are associated with increased likelihood of spontaneous vaginal birth, reduced medical interventions and increased maternal satisfaction.

An internet-based self-management program with telephone support for adolescents with arthritis: a pilot randomized controlled trial

OBJECTIVE

To determine the feasibility of a 12-week Internet-based self-management program of disease-specific information, self-management strategies, and social support with telephone support for youth with juvenile idiopathic arthritis (JIA) and their parents, aimed at reducing physical and emotional symptoms and improving health-related quality of life (HRQOL).

METHODS

A nonblind pilot randomized controlled trial (NCT01011179) was conducted to test the feasibility of the "Teens Taking Charge: Managing Arthritis Online" Internet intervention across 4 tertiary-level centers in Canada. Participants were 46 adolescents with JIA, ages 12 to 18 years, and 1 parent for each participant, who were randomized to the control arm (n = 24) or the Internet intervention (n = 22).

RESULTS

The 2 groups were comparable on demographic and disease-related variables and treatment expectation at baseline. Attrition rates were 18.1% and 20.8%, respectively, from experimental and control groups. Ninety-one percent of participants randomized to the experimental group completed all 12 online modules and weekly phone calls with a coach in an average of 14.7 weeks (SD 2.1). The control group completed 90% of weekly attention-control phone calls. The Internet treatment was rated as acceptable by all youth and their parents. In posttreatment the experimental group had significantly higher knowledge (p < 0.001, effect size 1.32) and lower average weekly pain intensity (p = 0.03, effect size 0.78). There were no significant group differences in HRQOL, self-efficacy, adherence, and stress posttreatment.

CONCLUSION

Findings support the feasibility (acceptability, compliance, and user satisfaction) and initial efficacy of Internet delivery of a self-management program for improving disease-specific knowledge and reducing pain in youth with JIA.

Support during pregnancy for women at increased risk of low birthweight babies

BACKGROUND

Studies consistently show a relationship between social disadvantage and low birthweight. Many countries have programs offering special assistance to women thought to be at risk for giving birth to a low birthweight infant. These programs may include advice and counseling (about nutrition, rest, stress management, alcohol, and recreational drug use), tangible assistance (e.g., transportation to clinic appointments, household help), and emotional support. The programs may be delivered by multidisciplinary teams of health professionals, specially trained lay workers, or combination of lay and professional workers.

OBJECTIVES

The primary objective was to assess effects of programs offering additional social support compared with routine care, for pregnant women believed at high risk for giving birth to babies that are either preterm or weigh less than 2500 gm, or both, at birth. Secondary objectives were to determine whether effectiveness of support was mediated by timing of onset (early versus later in pregnancy) or type of provider (healthcare professional or lay woman).

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2010).

SELECTION CRITERIA

Randomized trials of additional support during at-risk pregnancy by either a professional (social worker, midwife, or nurse) or specially trained lay person, compared to routine care. We defined additional support as some form of emotional support (e.g., counseling, reassurance, sympathetic listening) and information or advice or both, either in home visits or during clinic appointments, and could include tangible assistance (e.g., transportation to clinic appointments, assistance with care of other children at home).

DATA COLLECTION AND ANALYSIS

Two review authors evaluated methodological quality. We performed double data entry.

MAIN RESULTS

We included 17 trials (12,264 women). Programs offering additional social support for at-risk pregnant women were not associated with improvements in any perinatal outcomes, but there was a reduction in the likelihood of antenatal hospital admission (three trials; n = 737; RR 0.79, 95% CI 0.68 to 0.92) and caesarean birth (nine trials; n = 4522; RR 0.87, 95% CI 0.78 to 0.97).

AUTHORS' CONCLUSIONS

Pregnant women need the support of caring family members, friends, and health professionals. While programs which offer additional support during pregnancy are unlikely to prevent the pregnancy from resulting in a low birthweight or preterm baby, they may be helpful in reducing the likelihood of antenatal hospital admission and caesarean birth.

Re-conceptualizing the hospital labor room: the PLACE (pregnant and laboring in an ambient clinical environment) pilot trial

BACKGROUND

Nearly all hospitalized laboring women spend most of the time in bed. We made simple but radical modifications to a hospital labor room, which included the removal of the standard hospital bed and the addition of equipment to promote relaxation, mobility, and calm. We designed a pilot study, the objectives of which were to test the feasibility of a randomized trial and the acceptability of the modified labor room to women and their care providers.

METHODS

Women were assessed and invited to participate just before their admission to the labor and delivery suite. Sixty-two women at two Toronto teaching hospitals were randomly allocated to either the standard labor room or the "ambient room." Data about labor and birth events were abstracted from the medical records. Participants and their nurses and physicians completed questionnaires to elicit their views of their experiences with the labor rooms.

RESULTS

Women's and practitioners' evaluations of the ambient room were generally very positive. Nineteen women (65.5%) in the ambient group, compared with 4 (13.3%) in the standard group, reported spending 50 percent or less of their hospital labor in the standard labor bed. Twelve women allocated to the ambient room had artificial oxytocin infusions, compared with 21 allocated to the standard room (X (2) = 4.73, p = 0.03).

CONCLUSION

We conclude that the ambient labor room should be evaluated in an adequately powered randomized controlled trial.

WITHDRAWN: Continuity of caregivers for care during pregnancy and childbirth

BACKGROUND

Care during pregnancy, childbirth, and the postnatal period is often provided by multiple caregivers, many of whom work only in the antenatal clinic, labour ward or postnatal unit. However continuity of care is provided by the same caregiver or a small group from pregnancy through the postnatal period.

OBJECTIVES

The objective of this review was to assess continuity of care during pregnancy and childbirth and the puerperium with usual care by multiple caregivers.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register was searched. Date of last search: April 2000.

SELECTION CRITERIA

Controlled trials comparing continuity of care with usual care during pregnancy, childbirth and the postnatal period.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed. Study authors were contacted for additional information.

MAIN RESULTS

Two studies involving 1815 women were included. Both trials compared continuity of care by midwives with non-continuity of care by a combination of physicians and midwives. The trials were of good quality. Compared to usual care, women who had continuity of care from a team of midwives were less likely to be admitted to hospital antenatally (odds ratio 0.79, 95% confidence interval 0.64 to 0.97) and more likely to attend antenatal education programs (odds ratio 0.58, 95% confidence interval 0.41 to 0.81). They were also less likely to have drugs for pain relief during labour (odds ratio 0.53, 95% confidence interval 0.44 to 0.64) and their newborns were less likely to require resuscitation (odds ratio 0.66, 95% confidence interval 0.52 to 0.83). No differences were detected in Apgar scores, low birthweight and stillbirths or neonatal deaths. While they were less likely to have an episiotomy (odds ratio 0.75, 95% confidence interval 0.60 to 0.94), women receiving continuity of care were more likely to have either a vaginal or perineal tear (odds ratio 1.28, 95% confidence interval 1.05, 1.56). They were more likely to be pleased with their antenatal, intrapartum and postnatal care.

AUTHORS' CONCLUSIONS

Studies of continuity of care show beneficial effects. It is not clear whether these are due to greater continuity of care, or to midwifery care.

Effect on birth outcomes of a formalised approach to care in hospital labour assessment units: international, randomised controlled trial

OBJECTIVE

To determine if a complex nursing and midwifery intervention in hospital labour assessment units would increase the likelihood of spontaneous vaginal birth and improve other maternal and neonatal outcomes.

DESIGN

Multicentre, randomised controlled trial with prognostic stratification by hospital.

SETTING

20 North American and UK hospitals.

PARTICIPANTS

5002 nulliparous women experiencing contractions but not in active labour; 2501 were allocated to structured care and 2501 to usual care.

INTERVENTIONS

Usual nursing or midwifery care or a minimum of one hour of care by a nurse or midwife trained in structured care, consisting of a formalised approach to assessment of and interventions for maternal emotional state, pain, and fetal position.

MAIN OUTCOME MEASURES

Primary outcome was spontaneous vaginal birth. Other outcomes included intrapartum interventions, women's views of their care, and indicators of maternal and fetal health during hospital stay and 6-8 weeks after discharge.

RESULTS

Outcome data were obtained for 4996 women. The rate of spontaneous vaginal birth was 64.0% (n=1597) in the structured care group and 61.3% (n=1533) in the usual care group (odds ratio 1.12, 95% confidence interval 0.96 to 1.27). Fewer women allocated to structured care (n=403, 19.5%) rated staff helpfulness as less than very helpful than those allocated to usual care (n=544, 26.4%); odds ratio 0.67, 98.75% confidence interval 0.50 to 0.85. Fewer women allocated to structured care (n=233, 11.3%) were disappointed with the amount of attention received from staff than those allocated to usual care (n=407, 19.7%); odds ratio 0.51, 98.75% confidence interval 0.32 to 0.70. None of the other results met prespecified levels of statistical significance.

CONCLUSION

A structured approach to care in hospital labour assessment units increased satisfaction with care and was suggestive of a modest increase in the likelihood of spontaneous vaginal birth. Further study to strengthen the intervention is warranted.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN16315180.

Continuous support for women during childbirth

BACKGROUND

Historically, women have been attended and supported by other women during labour. However, in recent decades in hospitals worldwide, continuous support during labour has become the exception rather than the routine. Concerns about the consequent dehumanization of women's birth experiences have led to calls for a return to continuous support by women for women during labour.

OBJECTIVES

Primary: to assess the effects, on mothers and their babies, of continuous, one-to-one intrapartum support compared with usual care. Secondary: to determine whether the effects of continuous support are influenced by: (1) routine practices and policies in the birth environment that may affect a woman's autonomy, freedom of movement and ability to cope with labour; (2) whether the caregiver is a member of the staff of the institution; and (3) whether the continuous support begins early or later in labour.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2007).

SELECTION CRITERIA

All published and unpublished randomized controlled trials comparing continuous support during labour with usual care.

DATA COLLECTION AND ANALYSIS

We used standard methods of the Cochrane Collaboration Pregnancy and Childbirth Group. All authors participated in evaluation of methodological quality. One author and a research assistant independently extracted the data. We sought additional information from the trial authors. We used relative risk for categorical data and weighted mean difference for continuous data to present the results.

MAIN RESULTS

Sixteen trials involving 13,391 women met inclusion criteria and provided usable outcome data. Primary comparison: women who had continuous intrapartum support were likely to have a slightly shorter labour, were more likely to have a spontaneous vaginal birth and less likely to have intrapartum analgesia or to report dissatisfaction with their childbirth experiences. Subgroup analyses: in general, continuous intrapartum support was associated with greater benefits when the provider was not a member of the hospital staff, when it began early in labour and in settings in which epidural analgesia was not routinely available.

AUTHORS' CONCLUSIONS

All women should have support throughout labour and birth.

WITHDRAWN: Caregiver support for postpartum depression

BACKGROUND

Supportive relationships during the perinatal period may enhance a mother's feeling of wellbeing and control. Support to women during labour and after birth has shown benefits and this may also be the case for mothers with postpartum depression.

OBJECTIVES

The objective of this review was to assess the effect of professional and/or social support interventions for the treatment of postpartum depression.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register. Date of last search: January 2001.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing additional support from caregivers with usual forms of care in the postpartum period, in women who were clinically depressed in the six months after giving birth.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data were extracted by both reviewers. Study authors were contacted for additional information.

MAIN RESULTS

Two studies involving 137 women were included. There is potential for bias in at least one study, due to large numbers of women refusing to take part in the trial as well as significant losses to follow-up during the trial. Treatment of postpartum depression with support was associated with a reduction in depression at 25 weeks after giving birth (odds ratio 0.34, 95% confidence intervals 0.17 to 0.69).

AUTHORS' CONCLUSIONS

There is some indication that professional and/or social support may help in the treatment of postpartum depression. The types of support should be investigated to assess which models are most effective.

The costs of planned cesarean versus planned vaginal birth in the Term Breech Trial

BACKGROUND

The Term Breech Trial compared the safety of planned cesarean and planned vaginal birth for breech presentations at term. The combined outcome of perinatal or neonatal death and serious neonatal morbidity was found to be significantly lower among babies delivered by planned cesarean section. In this study we conducted a cost analysis of the 2 approaches to breech presentations at delivery.

METHODS

We used a third-party-payer (i.e., Ministry of Health) perspective. We included all costs for physician services and all hospital-related costs incurred by both the mother and the infant. We collected health care utilization and outcomes for all study participants during the trial. We used only the utilization data from countries with low national rates of perinatal death (< or = 20/1000). Seven hospitals across Canada (4 teaching and 3 community centres) were selected for unit cost calculations.

RESULTS

The estimated mean cost of a planned cesarean was significantly lower than that of a planned vaginal birth (7165 dollars v. 8042 dollars per mother and infant; mean difference -877 dollars, 95% credible interval -1286 dollars to -473 dollars). The estimated mean cost of a planned cesarean was lower than that of a planned vaginal birth for both women having a first birth (7255 dollars v. 8440 dollars) and women having had at least one prior birth (7071 dollars v. 7559 dollars). Although the treatment effect was largest in the subgroup of women having their first child, there was no statistically significant interaction between treatment and parity since the 95% credible intervals for difference in treatment effects between parity equalling zero and parity of one or greater all include zero.

INTERPRETATION

Planned cesarean section was found to be less costly than planned vaginal birth for the singleton fetus in a breech presentation at term in the Term Breech Trial.

The effect of unrestricted oral carbohydrate intake on labor progress

OBJECTIVE

To determine if unrestricted oral carbohydrate intake during labor reduced the incidence of dystocia in low-risk nulliparous women.

DESIGN AND SETTING

A randomized clinical trial at a university-affiliated hospital in southeastern Ontario. Low-risk nulliparous women were randomized between 30 and 40 weeks gestation to either an intervention or usual care group.

INTERVENTION

Women in the intervention group received, prenatally, guidelines about food and fluid intake during labor and were encouraged to eat and drink as they pleased during labor. Women in the usual care group received no prelabor information and were restricted to ice chips and water during labor in the hospital.

MAIN OUTCOME MEASURE

The incidence of dystocia, defined as a cervical dilatation rate of less than 0.5 cm/hr for a period of 4 hrs after a cervical dilatation of 3 cm.

RESULTS

Three hundred twenty-eight women were randomized to the intervention (n = 163) or usual care (n = 165) groups. Women in the intervention group reported a significantly different pattern of oral intake during early labor in the hospital (chi(2) = 40.7, p < .001). The incidence of dystocia was 36% (n = 58) in the intervention group and 44% (n = 72) in the usual care group and was not significantly different (OR = 0.71, 95% CI = 0.46, 1.11). There were no significant differences in the other secondary outcomes or in the incidence of adverse maternal or neonatal complications.

CONCLUSION

Eating and drinking early in labor had no significant impact on the incidence of dystocia and/or adverse maternal or neonatal outcomes.

Mothers’ Views of Their Childbirth Experiences 2 Years Mter Planned Caesarean Versus Planned Vaginal Birth for Breech Presentation at Term, in the International Randomized Term Breech Trial

OBJECTIVE

To compare mothers' views at 2 years postpartum after participation in a randomized trial of planned Caesarean and planned vaginal birth for a singleton fetus in breech presentation at term.

STUDY DESIGN

In selected centres in the Term Breech Trial, mothers completed a structured questionnaire at approximately 2 years postpartum to assess their likes and dislikes about their childbirth experiences and their views about their intrapartum care and care providers.

RESULTS

Of 1159 mothers from 85 centres, 917 (79.1%) completed a follow-up questionnaire at 2 years postpartum. Baseline information was similar for both the planned Caesarean and planned vaginal birth groups. Planned Caesarean was associated with less worry about the baby's health (P < 0.001). While other differences were noted in likes and dislikes about their childbirth experiences, women's evaluations of the quality of intrapartum care, the helpfulness of staff, and their involvement in decision-making did not differ in the planned Caesarean delivery and planned vaginal birth groups.

CONCLUSION

Planned mode of delivery influences aspects of women's evaluations of their childbirth experiences but does not affect evaluations of the quality of intrapartum care, support from care providers, or amount of involvement in decision-making.

Home-like versus conventional institutional settings for birth

BACKGROUND

Home-like birth settings have been established in or near conventional labour wards for the care of pregnant women who prefer and require little or no medical intervention during labour and birth.

OBJECTIVES

Primary: to assess the effects of care in a home-like birth environment compared to care in a conventional labour ward. Secondary: to determine if the effects of birth settings are influenced by staffing or organizational models or geographical location of the birth centre.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (18 May 2004) and handsearched eight journals and two published conference proceedings.

SELECTION CRITERIA

All randomized or quasi-randomized controlled trials that compared the effects of a home-like institutional birth environment to conventional hospital care.

DATA COLLECTION AND ANALYSIS

Standard methods of the Cochrane Collaboration Pregnancy and Childbirth Group were used. Two review authors evaluated methodological quality. Double data entry was performed. Results are presented using relative risks and 95% confidence intervals.

MAIN RESULTS

Six trials involving 8677 women were included. No trials of freestanding birth centres were found. Between 29% and 67% of women allocated to home-like settings were transferred to standard care before or during labour. Allocation to a home-like setting significantly increased the likelihood of: no intrapartum analgesia/anaesthesia (four trials; n = 6703; relative risk (RR) 1.19, 95% confidence interval (CI) 1.01 to 1.40), spontaneous vaginal birth (five trials; n = 8529; RR 1.03, 95% CI 1.01 to 1.06), vaginal/perineal tears (four trials; n = 8415; RR 1.08, 95% CI 1.03 to 1.13), preference for the same setting the next time (one trial; n = 1230; RR 1.81, 95% CI 1.65 to 1.98), satisfaction with intrapartum care (one trial; n = 2844; RR 1.14, 95% CI 1.07 to 1.21), and breastfeeding initiation (two trials; n = 1431; RR 1.05, 95% CI 1.02 to 1.09) and continuation to six to eight weeks (two trials; n = 1431; RR 1.06, 95% CI 1.02 to 1.10). Allocation to a home-like setting decreased the likelihood of episiotomy (five trials; n = 8529; RR 0.85, 95% CI 0.74 to 0.99). There was a trend towards higher perinatal mortality in the home-like setting (five trials; n = 8529; RR 1.83, 95% CI 0.99 to 3.38). No firm conclusions could be drawn regarding the effects of staffing or organizational models.

AUTHORS' CONCLUSIONS

When compared to conventional institutional settings, home-like settings for childbirth are associated with modest benefits, including reduced medical interventions and increased maternal satisfaction. Caregivers and clients should be vigilant for signs of complications.

Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial

OBJECTIVE

This study was undertaken to compare maternal outcomes at 2 years postpartum after planned cesarean section and planned vaginal birth for the singleton fetus in breech presentation at term.

STUDY DESIGN

In selected centers in the Term Breech Trial, mothers completed a structured questionnaire at 2 or more years postpartum to determine their health in the previous 3 to 6 months.

RESULTS

A total of 917 of 1159 (79.1%) mothers from 85 centers completed a follow-up questionnaire at 2 years postpartum. There were no differences between groups in breast feeding, relationship with child or partner, pain, subsequent pregnancy, incontinence, depression, urinary, menstrual or sexual problems, fatigue, or distressing memories of the birth experience. Planned cesarean section was associated with a higher risk of constipation (P = .02).

CONCLUSION

Maternal outcomes at 2 years postpartum are similar after planned cesarean section and planned vaginal birth for the singleton breech fetus at term.

Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial

OBJECTIVE

The purpose of this study was to determine whether planned cesarean delivery for the singleton fetus in breech presentation at term reduces the risk of death or neurodevelopmental delay at 2 years of age.

STUDY DESIGN

In selected centers in the Term Breech Trial, children were screened for abnormalities at > or =2 years of age with the Ages and Stages Questionnaire, followed by a neurodevelopmental assessment if the Ages and Stages Questionnaire score was abnormal.

RESULTS

A total of 923 of 1159 children (79.6%) from 85 centers were followed to 2 years of age. The risk of death or neurodevelopmental delay was no different for the planned cesarean than for the planned vaginal birth groups (14 children [3.1%] vs 13 children [2.8%]; relative risk, 1.09; 95% CI, 0.52- 2.30; P = .85; risk difference, +0.3%; 95% CI, -1.9%, +2.4%).

CONCLUSION

Planned cesarean delivery is not associated with a reduction in risk of death or neurodevelopmental delay in children at 2 years of age.

Support during pregnancy for women at increased risk of low birthweight babies

BACKGROUND

Studies consistently show a relationship between social disadvantage and low birthweight. Many countries have programs offering special assistance to women thought to be at risk for giving birth to a low birthweight infant. These programs may include advice and counselling (about nutrition, rest, stress management, alcohol and recreational drug use), tangible assistance (eg transportation to clinic appointments, help with household responsibilities), and emotional support. The programs may be delivered by multidisciplinary teams of health professionals, by specially trained lay workers, or by a combination of lay and professional workers.

OBJECTIVES

The objective of this review was to assess the effects of programs offering additional social support for pregnant women who are believed to be at risk for giving birth to preterm or low birthweight babies.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (30 January 2003).

SELECTION CRITERIA

Randomized trials of additional support during at-risk pregnancy by either a professional (social worker, midwife, or nurse) or specially trained lay person, compared to routine care. Additional support was defined as some form of emotional support (eg counselling, reassurance, sympathetic listening) and information/advice, either in home visits or during clinic appointments, and could include tangible assistance (eg transportation to clinic appointments, assistance with the care of other children at home).

DATA COLLECTION AND ANALYSIS

Reviewers independently assessed trial quality and extracted data. Double data entry was performed. Study authors were contacted to request additional information.

MAIN RESULTS

Sixteen trials involving 13,651 women were included. The trials were generally of good to excellent quality, although 3 used an allocation method likely to introduce bias. Programs offering additional social support for at-risk pregnant women were not associated with improvements in any perinatal outcomes, but there was a reduction in the likelihood of caesarean birth and an increased likelihood of elective termination of pregnancy. Some improvements in immediate maternal psychosocial outcomes were found in individual trials.

REVIEWER'S CONCLUSIONS

Pregnant women need the support of caring family members, friends, and health professionals. While programs which offer additional support during pregnancy are unlikely to prevent the pregnancy from resulting in a low birthweight or preterm baby, they may be helpful in reducing the likelihood of caesarean birth.

Continuous support for women during childbirth

BACKGROUND

Historically, women have been attended and supported by other women during labour. However, in recent decades in hospitals worldwide, continuous support during labour has become the exception rather than the routine. Concerns about the consequent dehumanization of women's birth experiences have led to calls for a return to continuous support by women for women during labour.

OBJECTIVES

Primary: to assess the effects, on mothers and their babies, of continuous, one-to-one intrapartum support compared with usual care. Secondary: to determine whether the effects of continuous support are influenced by: (1) routine practices and policies in the birth environment that may affect a woman's autonomy, freedom of movement, and ability to cope with labour; (2) whether the caregiver is a member of the staff of the institution; and (3) whether the continuous support begins early or later in labour.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (30 January 2003) and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2003).

SELECTION CRITERIA

All published and unpublished randomized controlled trials comparing continuous support during labour with usual care.

DATA COLLECTION AND ANALYSIS

Standard methods of the Cochrane Collaboration Pregnancy and Childbirth Group were used. All authors participated in evaluation of methodological quality. Data extraction was undertaken independently by one author and a research assistant. Additional information was sought from the trial authors. Results are presented using relative risk for categorical data and weighted mean difference for continuous data.

MAIN RESULTS

Fifteen trials involving 12,791 women are included. Primary comparison: Women who had continuous intrapartum support were less likely to have intrapartum analgesia, operative birth, or to report dissatisfaction with their childbirth experiences. Subgroup analyses: In general, continuous intrapartum support was associated with greater benefits when the provider was not a member of the hospital staff, when it began early in labour, and in settings in which epidural analgesia was not routinely available.

REVIEWER'S CONCLUSIONS

All women should have support throughout labour and birth.

Effectiveness of nurses as providers of birth labor support in North American hospitals: a randomized controlled trial

CONTEXT

North American cesarean delivery rates have risen dramatically since the 1960s, without concomitant improvements in perinatal or maternal health. A Cochrane Review concluded that continuous caregiver support during labor has many benefits, including reduced likelihood of cesarean delivery.

OBJECTIVE

To evaluate the effectiveness of nurses as providers of labor support in North American hospitals.

DESIGN

Randomized controlled trial with prognostic stratification by center and parity. Women were enrolled during a 2-year period (May 1999 to May 2001) and followed up until 6 to 8 postpartum weeks.

SETTING

Thirteen US and Canadian hospitals with annual cesarean delivery rates of at least 15%.

PARTICIPANTS

A total of 6915 women who had a live singleton fetus or twins, were 34 weeks' gestation or more, and were in established labor at randomization.

INTERVENTION

Patients were randomly assigned to receive usual care (n = 3461) or continuous labor support by a specially trained nurse (n = 3454) during labor.

MAIN OUTCOME MEASURES

The primary outcome measure was cesarean delivery rate. Other outcomes included intrapartum events and indicators of maternal and neonatal morbidity, both immediately after birth and in the first 6 to 8 postpartum weeks.

RESULTS

Data were received for all 6915 women and their infants (n = 6949). The rates of cesarean delivery were almost identical in the 2 groups (12.5% in the continuous labor support group and 12.6% in the usual care group; P =.44). There were no significant differences in other maternal or neonatal events during labor, delivery, or the hospital stay. There were no significant differences in women's perceived control during childbirth or in depression, measured at 6 to 8 postpartum weeks. All comparisons of women's likes and dislikes, and their future preference for amount of nursing support, favored the continuous labor support group.

CONCLUSIONS

In hospitals characterized by high rates of routine intrapartum interventions, continuous labor support by nurses does not affect the likelihood of cesarean delivery or other medical or psychosocial outcomes of labor and birth.

Pain and women's satisfaction with the experience of childbirth: a systematic review

OBJECTIVE

To summarize what is known about satisfaction with childbirth, with particular attention to the roles of pain and pain relief.

STUDY DESIGN

A systematic review of 137 reports of factors influencing women's evaluations of their childbirth experiences. The reports included descriptive studies, randomized controlled trials, and systematic reviews of intrapartum interventions. Results were summarized qualitatively.

RESULTS

Four factors-personal expectations, the amount of support from caregivers, the quality of the caregiver-patient relationship, and involvement in decision making-appear to be so important that they override the influences of age, socioeconomic status, ethnicity, childbirth preparation, the physical birth environment, pain, immobility, medical interventions, and continuity of care, when women evaluate their childbirth experiences.

CONCLUSION

The influences of pain, pain relief, and intrapartum medical interventions on subsequent satisfaction are neither as obvious, as direct, nor as powerful as the influences of the attitudes and behaviors of the caregivers.

Outcomes at 3 months after planned cesarean vs planned vaginal delivery for breech presentation at term: the international randomized Term Breech Trial

CONTEXT

The Term Breech Trial found a significant reduction in adverse perinatal outcomes without an increased risk of immediate maternal morbidity with planned cesarean delivery compared with planned vaginal birth. No randomized controlled trial of planned cesarean delivery has measured benefits and risks of postpartum outcomes months after the birth.

OBJECTIVE

To compare maternal outcomes of planned cesarean delivery and planned vaginal birth at 3 months post partum.

DESIGN

Follow-up study to the Term Breech Trial, a randomized controlled trial conducted between January 9, 1997, and April 21, 2000.

SETTING AND PARTICIPANTS

A total of 1596 of 1940 women from 110 centers worldwide who had a singleton fetus in breech presentation at term responded to a follow-up questionnaire at 3 months post partum.

MAIN OUTCOME MEASURES

Breastfeeding; infant health; ease of caring for infant and adjusting to being a new mother; sexual relations and relationship with husband/partner; pain; urinary, flatal, and fecal incontinence; depression; and views regarding childbirth experience and study participation.

RESULTS

Baseline information was similar for both the cesarean and vaginal delivery groups. Women in the planned cesarean delivery group were less likely to report urinary incontinence than those in the planned vaginal birth group (36/798 [4.5%] vs 58/797 [7.3%]; relative risk, 0.62; 95% confidence interval, 0.41-0.93). Incontinence of flatus was not different between groups but was less of a problem in the planned cesarean delivery group when it occurred (P =.006). There were no differences between groups in other outcomes.

CONCLUSIONS

Planned cesarean delivery for pregnancies with breech presentation at term may result in a lower risk of incontinence and is not associated with an increased risk of other problems for women at 3 months post partum, although the effect on longer-term outcomes is uncertain.

Promotion of breastfeeding intervention trial (PROBIT): a cluster-randomized trial in the Republic of Belarus. Design, follow-up, and data validation

This paper summarizes the objectives, design, follow-up, and data validation of a cluster-randomized trial of a breastfeeding promotion intervention modeled on the WHO/UNICEF Baby-Friendly Hospital Initiative (BFHI). Thirty-four hospitals and their affiliated polyclinics in the Republic of Belarus were randomized to receive BFHI training of medical, midwifery, and nursing staffs (experimental group) or to continue their routine practices (control group). All breastfeeding mother-infant dyads were considered eligible for inclusion in the study if the infant was singleton, born at > or = 37 weeks gestation, weighed > or = 2500 grams at birth, and had a 5-minute Apgar score > or = 5, and neither mother nor infant had a medical condition for which breastfeeding was contraindicated. One experimental and one control site refused to accept their randomized allocation and dropped out of the trial. A total of 17,795 mothers were recruited at the 32 remaining sites, and their infants were followed up at 1, 2, 3, 6, 9, and 12 months of age. To our knowledge, this is the largest randomized trial ever undertaken in area of human milk and lactation. Monitoring visits of all experimental and control maternity hospitals and polyclinics were undertaken prior to recruitment and twice more during recruitment and follow-up to ensure compliance with the randomized allocation. Major study outcomes include the occurrence of > or = 1 episode of gastrointestinal infection, > or = 2 respiratory infections, and the duration of breastfeeding, and are analyzed according to randomized allocation ("intention to treat"). One of the 32 remaining study sites was dropped from the trial because of apparently falsified follow-up data, as suggested by an unrealistically low incidence of infection and unrealistically long duration of breastfeeding, and as confirmed by subsequent data audit of polyclinic charts and interviews with mothers of 64 randomly-selected study infants at the site. Smaller random audits at each of the remaining sites showed extremely high concordance between the PROBIT data forms and both the polyclinic charts and maternal interviews, with no evident difference in under- or over-reporting in experimental vs control sites. Of the 17,046 infants recruited from the 31 participating study sites, 16,491 (96.7%) completed the study and only 555 (3.3%) were lost to follow-up. PROBIT's results should help inform decision-making for clinicians, hospitals, industry, and governments concerning the support, protection, and promotion of breastfeeding.

Promotion of Breastfeeding Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus

CONTEXT

Current evidence that breastfeeding is beneficial for infant and child health is based exclusively on observational studies. Potential sources of bias in such studies have led to doubts about the magnitude of these health benefits in industrialized countries.

OBJECTIVE

To assess the effects of breastfeeding promotion on breastfeeding duration and exclusivity and gastrointestinal and respiratory infection and atopic eczema among infants.

DESIGN

The Promotion of Breastfeeding Intervention Trial (PROBIT), a cluster-randomized trial conducted June 1996-December 1997 with a 1-year follow-up.

SETTING

Thirty-one maternity hospitals and polyclinics in the Republic of Belarus.

PARTICIPANTS

A total of 17 046 mother-infant pairs consisting of full-term singleton infants weighing at least 2500 g and their healthy mothers who intended to breastfeed, 16491 (96.7%) of which completed the entire 12 months of follow-up.

INTERVENTIONS

Sites were randomly assigned to receive an experimental intervention (n = 16) modeled on the Baby-Friendly Hospital Initiative of the World Health Organization and United Nations Children's Fund, which emphasizes health care worker assistance with initiating and maintaining breastfeeding and lactation and postnatal breastfeeding support, or a control intervention (n = 15) of continuing usual infant feeding practices and policies.

MAIN OUTCOME MEASURES

Duration of any breastfeeding, prevalence of predominant and exclusive breastfeeding at 3 and 6 months of life and occurrence of 1 or more episodes of gastrointestinal tract infection, 2 or more episodes of respiratory tract infection, and atopic eczema during the first 12 months of life, compared between the intervention and control groups.

RESULTS

Infants from the intervention sites were significantly more likely than control infants to be breastfed to any degree at 12 months (19.7% vs 11.4%; adjusted odds ratio [OR], 0.47; 95% confidence interval [CI], 0.32-0.69), were more likely to be exclusively breastfed at 3 months (43.3% vs 6.4%; P<.001) and at 6 months (7.9% vs 0.6%; P =.01), and had a significant reduction in the risk of 1 or more gastrointestinal tract infections (9.1% vs 13.2%; adjusted OR, 0.60; 95% CI, 0.40-0.91) and of atopic eczema (3.3% vs 6.3%; adjusted OR, 0.54; 95% CI, 0.31-0.95), but no significant reduction in respiratory tract infection (intervention group, 39.2%; control group, 39.4%; adjusted OR, 0.87; 95% CI, 0.59-1.28).

CONCLUSIONS

Our experimental intervention increased the duration and degree (exclusivity) of breastfeeding and decreased the risk of gastrointestinal tract infection and atopic eczema in the first year of life. These results provide a solid scientific underpinning for future interventions to promote breastfeeding.

Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group

BACKGROUND

For 3-4% of pregnancies, the fetus will be in the breech presentation at term. For most of these women, the approach to delivery is controversial. We did a randomised trial to compare a policy of planned caesarean section with a policy of planned vaginal birth for selected breech-presentation pregnancies.

METHODS

At 121 centres in 26 countries, 2088 women with a singleton fetus in a frank or complete breech presentation were randomly assigned planned caesarean section or planned vaginal birth. Women having a vaginal breech delivery had an experienced clinician at the birth. Mothers and infants were followed-up to 6 weeks post partum. The primary outcomes were perinatal mortality, neonatal mortality, or serious neonatal morbidity; and maternal mortality or serious maternal morbidity. Analysis was by intention to treat.

FINDINGS

Data were received for 2083 women. Of the 1041 women assigned planned caesarean section, 941 (90.4%) were delivered by caesarean section. Of the 1042 women assigned planned vaginal birth, 591 (56.7%) delivered vaginally. Perinatal mortality, neonatal mortality, or serious neonatal morbidity was significantly lower for the planned caesarean section group than for the planned vaginal birth group (17 of 1039 [1.6%] vs 52 of 1039 [5.0%]; relative risk 0.33 [95% CI 0.19-0.56]; p<0.0001). There were no differences between groups in terms of maternal mortality or serious maternal morbidity (41 of 1041 [3.9%] vs 33 of 1042 [3.2%]; 1.24 [0.79-1.95]; p=0.35).

INTERPRETATION

Planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups.

Prelabor rupture of the membranes at term: expectant management at home or in hospital? The TermPROM Study Group

OBJECTIVE

To determine whether adverse effects of expectant management for premature rupture of membranes (PROM) at term and patient satisfaction were greater if women were managed at home rather than in a hospital.

METHODS

We undertook a secondary analysis of data from the International TermPROM Study for women managed expectantly at home or in a hospital. Using multiple logistic regression analyses, we determined the effect of home and hospital management and controlled for differences in baseline characteristics, in measures of maternal and neonatal infections and rates of cesarean.

RESULTS

Six hundred fifty-three women (39.1%) were managed at home, and 1017 (60.9%) in a hospital. Management at home, compared with in a hospital, increased risk of nulliparas needing antibiotics before delivery (odds ratio [OR] 1.52 95% confidence interval [CI] 1.04, 2.24, P =.03), those not colonized with group B streptococcus having cesareans (OR 1.48 95% CI 1.03, 2. 14, P =.04), and neonatal infections (OR 1.97 95% CI 1.00, 3.90, P =. 05). More multiparas managed at home said they would participate in the study again (OR 1.80 95% CI 1.27, 2.54, P <.001).

CONCLUSION

Expectant management at home, rather than in a hospital, might increase the likelihood of some adverse outcomes.

Home-like versus conventional institutional settings for birth

BACKGROUND

Many home-like birth centres have been established near conventional labour wards for the care of pregnant women who prefer and require little or no medical intervention during labour and birth.

OBJECTIVES

The objective of this review was to assess the effects of care in a home-like birth environment compared to care in a conventional labour ward, on labour and birth outcomes.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register was searched.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing a home-like institutional birth environment to conventional hospital care for pregnant women at low risk of obstetric complications.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed.

MAIN RESULTS

Five trials involving almost 8000 women were included. Substantial numbers of women allocated to home-like settings were transferred to standard care before or during labour, making interpretation of results difficult. Allocation to a home-like setting was associated with lower rates of intrapartum analgesia/anaesthesia (odds ratio 0.82, 95% confidence interval 0.72 to 0.93), fetal heart rate abnormalities (0.72, 95% confidence interval 0.63 to 0.81), augmented labour, and immobility during labour, as well as greater satisfaction with care, and increased likelihood of sore nipples and mastitis. There was a non-statistically significant trend towards higher perinatal mortality in the home-like setting (odds ratio 1.49, 95% confidence interval 0.79 to 2.78).

REVIEWER'S CONCLUSIONS

There appear to be some benefits from home-like settings for childbirth, although increased support from caregivers may be more important. Caregivers and clients in home-like settings need to watch for signs of complications.

Caregiver support for women during childbirth

BACKGROUND

Social support may include advice or information, tangible assistance and emotional support.

OBJECTIVES

The objective of this review was to assess the effects of continuous support during labour (provided by health care workers or lay people) on mothers and babies.

SEARCH STRATEGY

I searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register. Date of last search: April 1999.

SELECTION CRITERIA

Randomised trials comparing continuous support during labour with usual care.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed. Study authors were contacted for additional information.

MAIN RESULTS

Fourteen trials, involving more than 5000 women, are included in the Review. The continuous presence of a support person reduced the likelihood of medication for pain relief, operative vaginal delivery, caesarean delivery, and a 5-minute Apgar score less than 7. Continuous support was also associated with a slight reduction in the length of labour. Six trials evaluated the effects of support on mothers' views of their childbirth experiences; while the trials used different measures (overall satisfaction, failure to cope well during labour, finding labour to be worse than expected, and level of personal control during childbirth), in each trial the results favoured the group who had received continuous support.

REVIEWER'S CONCLUSIONS

Continuous support during labour from caregivers (nurses, midwives or lay people) appears to have a number of benefits for mothers and their babies and there do not appear to be any harmful effects.

Caregiver support for postpartum depression

BACKGROUND

Supportive relationships during the perinatal period may enhance a mother's feeling of wellbeing and control. Support to women during labour and after birth has shown benefits and this may also be the case for mothers with postpartum depression.

OBJECTIVES

The objective of this review was to assess the effect of professional and/or social support interventions for the treatment of postpartum depression.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing additional support from caregivers with usual forms of care in the postpartum period, in women who were clinically depressed in the six months after giving birth.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data were extracted by both reviewers. Study authors were contacted for additional information.

MAIN RESULTS

Two studies involving 137 women were included. There is potential for bias in at least one study, due to large numbers of women refusing to take part in the trial as well as significant losses to follow-up during the trial. Treatment of postpartum depression with support was associated with a reduction in depression at 25 weeks after giving birth (odds ratio 0.34, 95% confidence intervals 0.17 to 0.69).

REVIEWER'S CONCLUSIONS

There is some indication that professional and/or social support may help in the treatment of postpartum depression. The types of support should be investigated to assess which models are most effective.

Home-based social support for socially disadvantaged mothers

BACKGROUND

Epidemiologic studies indicate that babies born to socio-economically disadvantaged mothers are at higher risk of injury, abuse and neglect, health problems in infancy, and are less likely to have regular well-child care. Home visitation programs have long been advocated as a strategy for improving the health of disadvantaged children. Over the past two decades, a number of randomised trials have examined the effect of home visitation programs on a range of maternal and child health outcomes. The studies in this review evaluate programs which offer additional home based support for socially disadvantaged mothers and their children.

OBJECTIVES

Babies born in socio-economic disadvantage are likely to be at higher risk of injury, abuse and neglect, and to have health problems in infancy. The objective of this review was to assess the effects of programs offering additional home-based support for women who have recently given birth and who are socially disadvantaged.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register. Date of last search: 26 October 1998.

SELECTION CRITERIA

Randomised and quasi-randomised trials of one or more post-natal home visits with the aim of providing additional home based support for socially disadvantaged women who had recently given birth, compared to usual care.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed. Study authors were contacted for additional information.

MAIN RESULTS

Eleven studies, involving 2992 families, were included. Most of the trials had important methodological limitations. Seven trial reports are awaiting further assessment. There was a trend towards reduced child injury rates with additional support, although this was not statistically significant (odds ratio 0.74, 95% confidence interval 0.54 to 1.03). There appeared to be no difference for child abuse and neglect (odds ratio 1.12, 95% confidence interval 0.80 to 1.57), although differential surveillance between visited and non-visited families is an important methodological consideration. Babies in the additional support groups were more likely to have complete well-child immunizations. Based on the results of two trials, there was a trend towards reduced hospitalization, although this was not statistically significant.

REVIEWER'S CONCLUSIONS

Postnatal home-based support programs appear to have no risks and may have benefits for socially disadvantaged mothers and their children, possibly including reduced rates of child injury. Differential surveillance does not allow easy interpretation of the child abuse and neglect findings.

Continuity of caregivers for care during pregnancy and childbirth

BACKGROUND

Care is often provided by multiple caregivers, many of whom work only in the antenatal clinic, labour ward or postnatal unit. However continuity of care is provided by the same caregiver or a small group from pregnancy through the postnatal period.

OBJECTIVES

The objective of this review was to assess continuity of care during pregnancy and childbirth and the puerperium with usual care by multiple caregivers.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register was searched.

SELECTION CRITERIA

Controlled trials comparing continuity of care with usual care during pregnancy, childbirth and the postnatal period.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed. Study authors were contacted for additional information.

MAIN RESULTS

Two studies involving 1815 women were included. Both trials compared continuity of care by midwives with non-continuity of care by a combination of physicians and midwives. The trials were of good quality. Compared to usual care, women who had continuity of care from a team of midwives were less likely to be admitted to hospital antenatally (odds ratio 0.79, 95% confidence interval 0.64 to 0.97) and more likely to attend antenatal education programs (odds ratio 0.58, 95% confidence interval 0.41 to 0.81). They were also less likely to have drugs for pain relief during labour (odds ratio 0.53, 95% confidence interval 0.44 to 0.64) and their newborns were less likely to require resuscitation (odds ratio 0.66, 95% confidence interval 0.52 to 0.83). No differences were detected in Apgar scores, low birthweight and stillbirths or neonatal deaths. While they were less likely to have an episiotomy (odds ratio 0.75, 95% confidence interval 0.60 to 0.94), women receiving continuity of care were more likely to have either a vaginal or perineal tear (odds ratio 1.28, 95% confidence interval 1.05, 1.56). They were more likely to be pleased with their antenatal, intrapartum and postnatal care.

REVIEWER'S CONCLUSIONS

Studies of continuity of care show beneficial effects. It is not clear whether these are due to greater continuity of care, or to midwifery care.

Tocolytics for preterm labor: a systematic review

OBJECTIVE

To examine the effectiveness of any tocolytic compared with a placebo or no tocolytic for preterm labor.

DATA SOURCES

We checked MEDLINE (1966-1998) and the Cochrane Controlled Trials Register for articles, using the search terms "randomized controlled trial" (RCT), "preterm labor," "tocolysis," "betamimetics," "ritodrine," "terbutaline," "hexaprenaline," "isoxuprine," "prostaglandin synthetase inhibitors," "indomethacin," "sulindac," "calcium channel blockers," "nifedipine," "oxytocin receptor blockers," "atosiban," "nitroglceride," and "magnesium sulfate."

METHODS OF STUDY SELECTION

We included all RCTs that compared effect of a tocolytic with a placebo or no tocolytic in women in preterm labor, and reported perinatal, neonatal, or maternal outcomes. Studies were excluded if loss to follow-up exceeded 20% of those originally enrolled, or if data were not reported on a per-patient-treated basis. Eighteen of 76 articles retrieved met the inclusion criteria.

TABULATION, INTEGRATION, AND RESULTS

Two authors independently reviewed the articles and abstracted the data. Discrepancies were resolved by consensus. Meta-analyses (odds ratio [OR] and 95% confidence interval [CI]) were done for each outcome for all trials and for specific types of tocolytic therapy when possible. Tocolytics decreased the risk of delivery within 7 days (OR 0.60, 95% CI 0.38, 0.95). Betamimetics, indomethacin, atosiban, and ethanol, but not magnesium sulfate, were associated with significant prolongations in pregnancy. Tocolytics were not associated with improved perinatal outcomes. Maternal side effects significantly associated with tocolytic use were palpitations, nausea, tremor, chorioamnionitis, hyperglycemia, hypokalemia, and need to discontinue treatment.

CONCLUSION

Although tocolytics prolong pregnancy, they have not been shown to improve perinatal or neonatal outcomes and have adverse effects on women in preterm labor.

Predictors of cesarean delivery after prelabor rupture of membranes at term

OBJECTIVE

To identify the significant predictors of cesarean delivery after prelabor rupture of membranes (PROM) at term.

METHODS

In a multicenter study involving 72 institutions in six countries, 5041 women were randomized to induction of labor with oxytocin or prostaglandins or to expectant management. We did univariate and multivariate logistic regression analyses to determine the statistically significant independent predictors of cesarean delivery (P < .05).

RESULTS

The following variables were found to be significantly associated with cesarean delivery: delivery in Israel, versus Canada (odds ratio [OR] 0.34); delivery in Australia, versus Canada (OR 1.93); nulliparity (OR 2.81); labor lasting more than 12 hours, versus less than 6 hours (OR 2.78); labor lasting 6-12 hours, versus less than 6 hours (OR 1.66); previous cesarean delivery (OR 2.75); epidural anesthesia (OR 2.66); clinical chorioamnionitis (OR 2.42); internal fetal heart rate monitoring (OR 2.19); birth weight of at least 4000 g (OR 2.07); use of oxytocin (OR 1.97); maternal age of at least 35 years (OR 1.44); latent period of at least 12 hours (OR 1.41); and meconium staining (OR 1.41).

CONCLUSION

Strong predictors of cesarean delivery after PROM at term were country of birth, nulliparity, long labor, previous cesarean delivery, and epidural anesthesia.

Women's evaluations of induction of labor versus expectant management for prelabor rupture of the membranes at term. TermPROM Study Group

BACKGROUND

Induction of labor has become common practice in many Western countries, but few studies have assessed women's views.

METHODS

A randomized, controlled trial was conducted at 72 hospitals in six countries. Five thousand forty-one women meeting eligibility criteria, with no contraindications for induction of labor or expectant management, were randomly assigned to four groups: induction with intravenous oxytocin, induction with vaginal prostaglandin E2 gel, or expectant management followed by induction with either oxytocin or with prostaglandin E2 gel if complications developed. The three main outcome measures were evaluations of the treatment received, perceived control during childbirth, and evaluations of the experience of trial participation.

RESULTS

Questionnaires were completed by 81.9 percent of the sample. No significant differences occurred between the two induction groups. Compared with the expectant management groups, induced women were less likely to report there was nothing they liked about their treatment and less likely to report that the treatment caused additional worry. No between-group differences occurred in experienced control during childbirth. Women in the induction groups were more likely to be willing to participate in the study again and to feel reassured.

CONCLUSIONS

Women's preferences should be considered when making decisions about their method of management when membranes rupture before labor. Obtaining participants' views is both feasible and worthwhile when evaluating forms of medical care.

Induction of labour versus expectant management for prelabour rupture of the membranes at term: an economic evaluation. TERMPROM Study Group. Term Prelabour Rupture of the Membranes

BACKGROUND

As the interval between rupture of the fetal membranes at term and delivery increases, so may the risk of fetal and maternal infection. Recently the TERMPROM (Term Prelabor Rupture of the Membranes) Study Group reported the results of a randomized controlled trial comparing 4 management strategies: induction with oxytocin (IwO), induction with prostaglandin (IwP), and expectant management and induction with either oxytocin (EM-O) or prostaglandin (EM-P) if complications developed. The study found no statistically significant differences in neonatal infection and cesarean section rates between any of the 4 groups.

OBJECTIVE

To conduct an economic evaluation comparing the cost of (a) IwO and EM-O, (b) IwP and EM-P and (c) IwO and IwP.

DESIGN

An economic analysis, conducted alongside the clinical trial, using a third-party payer perspective. Analysis included all treatment costs incurred for both the mother and the baby. Information on health care utilization and outcomes was collected for all study participants. Three countries (Canada, the United Kingdom and Australia), corresponding to the largest study recruitment, were chosen for calculation of unit costs. For each country, the base, low and high estimates of unit cost for each service item were generated. Intention-to-treat analysis. Extensive statistical and sensitivity analyses were performed.

RESULTS

The median cost of IwO per patient was significantly lower statistically than that of EM-O and IwP. This result held in all 3 countries compared -$114 and -$46 in Canada, -113 Pounds and -63 Pounds in the UK, and -A$30 and -A$49 in Australia) and after an extensive sensitivity analysis. There was no statistically significant difference in median cost per patient between IwP and EM-P.

CONCLUSION

Although the clinical results of the TERMPROM study did not find IwO to be preferable to the other treatment alternatives, the economic evaluation found it to be less costly. However, these cost differences, even though statistically significant, are not likely to be important in many countries. When this is the case, the authors recommend that women be offered a choice between management strategies.

International Multicentre Term Prelabor Rupture of Membranes Study: evaluation of predictors of clinical chorioamnionitis and postpartum fever in patients with prelabor rupture of membranes at term

OBJECTIVES

Our purpose was to determine significant predictors for the development of clinical chorioamnionitis and postpartum fever in patients with prelabor rupture of membranes at term.

STUDY DESIGN

Logistic regression analysis with odds ratios and 95% confidence intervals was used to determine the significant predictors of clinical chorioamnionitis and postpartum fever in women with prelabor rupture of membranes at term enrolled in this study. The study recently compared in a randomized controlled trial four strategies of management: induction with oxytocin, induction with prostaglandin, expectant management, and, if failed, induction with oxytocin or prostaglandin.

RESULTS

The following variables were significantly associated with clinical chorioamnionitis: (1) number of digital vaginal examinations: > 8, 7 to 8, 5 to 6, 3 to 4 (vs 0 to 2) (odds ratio 5.07, 3.80, 2.62, 2.06); (2) duration of active labor: > or = 12, 9 to < 12, 6 to < 9 hours (vs < 3 hours) (odds ratio 4.12, 2.94, 1.97); (3) meconium-stained amniotic fluid (odds ratio 2.28); (4) parity of 0 (odds ratio 1.80); (5) time from membrane rupture to active labor: > or = 48, 24 to < 48 hours (vs < 12 hours) (odds ratio 1.76, 1.77); and (6) group B streptococcal colonization (odds ratio 1.71). Variables significantly associated with postpartum fever were (1) clinical chorioamnionitis (odds ratio 5.37), (2) duration of active labor: > or = 12, 9 to < 12, 6 to < 9, 2 to < 6 hours (vs < 3 hours) (odds ratio 4.86, 3.53, 3.46, 3.04), (3) cesarean section, operative vaginal delivery (odds ratio 3.97, 1.86), (4) group B streptococcal colonization (odds ratio 1.88), and (5) maternal antibiotics before delivery (odds ratio 1.94).

CONCLUSIONS

Increasing numbers of digital vaginal examinations, longer duration of active labor, and meconium staining of the amniotic fluid were the most important risk factors for the development of clinical chorioamnionitis in women with prelabor rupture of membranes at term. The most important risk factors for the development of postpartum fever were clinical chorioamnionitis, increasing duration of active labor, and cesarean section delivery.

Maternal colonization with group B Streptococcus and prelabor rupture of membranes at term: the role of induction of labor. TermPROM Study Group

OBJECTIVES

Our purpose was to determine the effect of induction of labor on neonatal infection if mothers are group B streptococci positive and have prelabor rupture of membranes at term.

STUDY DESIGN

In the TermPROM study 5041 women were randomized to induction with intravenous oxytocin, induction with vaginal prostaglandin E2 gel, or expectant management with induction, if needed. Of these, 4834 women had vaginal or introital swabs for group B streptococci taken at entry. We used logistic regression to test for effects of treatment within group B streptococci subgroups.

RESULTS

Group B streptococci were predictive of neonatal infection for the induction with vaginal prostaglandin E2 gel and expectant groups but not for the induction with oxytocin group. For women positive for group B streptococci the rates of neonatal infection were 2.5% for the induction with oxytocin group and > 8% for all other groups.

CONCLUSIONS

Induction of labor with intravenous oxytocin may be preferable for group B streptococci-positive women with prelabor rupture of membranes at term.

Induction of labor compared with expectant management for prelabor rupture of the membranes at term. TERMPROM Study Group

BACKGROUND

As the interval between rupture of the fetal membranes at term and delivery increases, so may the risk of fetal and maternal infection. It is not known whether inducing labor will reduce this risk or whether one method of induction is better then another.

METHODS

We studied 5041 women with prelabor rupture of the membranes at term. The women were randomly assigned to induction of labor with intravenous oxytocin; induction of labor with vaginal prostaglandin E2 gel; or expectant management for up to four days, with labor induced with either intravenous oxytocin or vaginal prostaglandin E2 gel if complications developed. The primary outcome was neonatal infection. Secondary outcomes were the need for cesarean section and women's evaluations of their treatment.

RESULTS

The rates of neonatal infection and cesarean section were not significantly different among the study groups. The rates of neonatal infection were 2.0 percent for the induction-with-oxytocin group, 3.0 percent for the induction-with-prostaglandin group, 2.8 percent for the expectant-management (oxytocin) group, and 2.7 percent for the expectant-management (prostaglandin) group. The rates of cesarean section ranged from 9.6 to 10.9 percent. Clinical chorioamnionitis was less likely to develop in the women in the induction-with-oxytocin group than in those in the expectant-management (oxytocin) group (4.0 percent vs. 8.6 percent, P<0.001), as was postpartum fever (1.9 percent vs. 3.6 percent, P=0.008). Women in the induction groups were less likely to say they liked "nothing" about their treatment than those in the expectant-management groups.

CONCLUSIONS

In women with prelabor rupture of the membranes at term, induction of labor with oxytocin or prostaglandin E2 and expectant management result in similar rates of neonatal infection and cesarean section. Induction of labor with intravenous oxytocin results in a lower risk of maternal infection than does expectant management. Women view induction of labor more positively than expectant management.