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1.  Diverse definitions of prolonged labour and its consequences with sometimes subsequent inappropriate treatment 
Background
Prolonged labour very often causes suffering from difficulties that may have lifelong implications. This study aimed to explore the prevalence and treatment of prolonged labour and to compare birth outcome and women’s experiences of prolonged and normal labour.
Method
Women with spontaneous onset of labour, living in a Swedish county, were recruited two months after birth, to a cross-sectional study. Women (n = 829) completed a questionnaire that investigated socio-demographic and obstetric background, birth outcome and women’s feelings and experiences of birth. The prevalence of prolonged labour, as defined by a documented ICD-code and inspection of partogram was calculated. Four groups were identified; women with prolonged labour as identified by documented ICD-codes or by partogram inspection but no ICD-code; women with normal labour augmented with oxytocin or not.
Results
Every fifth woman experienced a prolonged labour. The prevalence with the documented ICD-code was (13%) and without ICD-code but positive partogram was (8%). Seven percent of women with prolonged labour were not treated with oxytocin. Approximately one in three women (28%) received oxytocin augmentation despite having no evidence of prolonged labour. The length of labour differed between the four groups of women, from 7 to 23 hours.
Women with a prolonged labour had a negative birth experience more often (13%) than did women who had a normal labour (3%) (P <0.00). The factors that contributed most strongly to a negative birth experience in women with prolonged labour were emergency Caesarean section (OR 9.0, 95% CI 1.2-3.0) and to strongly agree with the following statement ‘My birth experience made me decide not to have any more children’ (OR 41.3, 95% CI 4.9-349.6). The factors that contributed most strongly to a negative birth experience in women with normal labour were less agreement with the statement ‘It was exiting to give birth’ (OR 0.13, 95% CI 0.34-0.5).
Conclusions
There is need for increased clinical skill in identification and classification of prolonged labour, in order to improve care for all women and their experiences of birthing processes regardless whether they experience a prolonged labour or not.
doi:10.1186/1471-2393-14-233
PMCID: PMC4105110  PMID: 25031035
Birth experience; Dystocia; Prolonged labour
2.  Methods for assessing pre-induction cervical ripening 
Background
Induction of labour is the artificial initiation of labour in a pregnant woman after the age of fetal viability but without any objective evidence of active phase labour and with intact fetal membranes. The need for induction of labour may arise due to a problem in the mother, her fetus or both, and the procedure may be carried out at or before term. Obstetricians have long known that for this to be successful, it is important that the uterine cervix (the neck of the womb) has favourable characteristics in terms of readiness to go into the labour state.
Objectives
To compare Bishop score with any other method for assessing pre-induction cervical ripening in women admitted for induction of labour.
Search methods
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2015) and reference lists of retrieved studies to identify randomised controlled trials (RCTs).
Selection criteria
All RCTs comparing Bishop score with any other methods of pre-induction cervical assessment in women admitted for induction of labour. Cluster-RCTs were eligible for inclusion but none were identified. Quasi-RCTs and studies using a cross-over design were not eligible for inclusion. Studies published in abstract form were eligible for inclusion if they provided sufficient information.
Comparisons could include the following.
Bishop score versus transvaginal ultrasound (TVUS).
Bishop score versus Insulin-like growth factor binding protein-1 (IGFBP-1).
Bishop score versus vaginal fetal fibronectin (fFN).
However, we only identified data for a comparison of Bishop score versus TVUS.
Data collection and analysis
Two review authors independently assessed the trials for inclusion, extracted the data and assessed trial quality. Data were checked for accuracy.
Main results
We included two trials that recruited a total of 234 women. The overall risk of bias was low for the two studies. Both studies compared Bishop score withTVUS.
The two included studies did not show any clear difference between the Bishop score and TVUS groups for the following main outcomes: vaginal birth (RR 1.07, 95% CI 0.92 to 1.25, moderate quality evidence), caesarean delivery (RR 0.81, 95% CI 0.49 to 1.34, moderate quality evidence), neonatal admission into neonatal intensive care unit (RR 1.67, 95% CI 0.41 to 6.71, moderate quality evidence). Both studies only provided median data in relation to induction-delivery interval and reported no clear difference between the Bishop and TVUS groups. Perinatal mortality was not reported in the included studies.
For the review's secondary outcomes, the need for misoprostol for cervical ripening was more frequent in the TVUS group compared to the Bishop score group (RR 0.52, 95% CI 0.41 to 0.66, two studies, 234 women, moderate quality evidence). In contrast, there were no clear differences between the Bishop scope and TVUS groups in terms of meconium staining of the amniotic fluid, fetal heart rate abnormality in labour, and Apgar score less than seven. Only one trial reported median data on the induction-delivery interval and induction to active phase interval, the trialist reported no difference between the Bishop group and the TVUS group for this outcome. Neither of the included studies reported on uterine rupture.
Authors' conclusions
Moderate quality evidence from two small RCTs involving 234 women that compared two different methods for assessing pre-induction cervical ripening (Bishop score and TVUS) did not demonstrate superiority of one method over the other in terms of the main outcomes assessed in this review. We did not identify any data relating to perinatal mortality. Whilst use of TVUS was associated with an increased need for misoprostol for cervical ripening, both methods could be complementary.
The choice of a particular method of assessing pre-induction cervical ripening may differ depending on the environment and need where one is practicing since some methods (i.e. TVUS) may not be readily available and affordable in resource-poor settings where the sequelae of labour and its management is prevalent.
The evidence in this review is based on two studies that enrolled a small number of women and there is insufficient evidence to support the use of TVUS over the standard digital vaginal assessment in pre-induction cervical ripening. Further adequately powered RCTs involving TVUS and the Bishop score and including other methods of pre-induction cervical ripening assessment are warranted. Such studies need to address uterine rupture, perinatal mortality, optimal cut-off value of the cervical length and Bishop score to classify women as having favourable or unfavourable cervices and cost should be included as an outcome.
PLAIN LANGUAGE SUMMARY
Methods for assessing pre-induction cervical ripening, the ability of the cervix to open in response to spontaneous uterine contractions
In this review, researchers from The Cochrane Collaboration examined a comparison between the Bishop score and any other method for checking pre-induction cervical ripening in women admitted for induction of labour. The Bishop score is the traditional method of determining the readiness of the cervix to open (dilate) before labour induction. It also assesses the position, softening and shortening of the cervix, and the location of the presenting part of the baby. After searching for relevant trials up to 31 March 2015, we included two randomised controlled trials that recruited 234 pregnant women.
What are the methods for pre-induction softening of the neck of womb and why is it important to soften the neck of womb before induction of labour?
Induction of labour is the non-natural process of starting labour in a pregnant woman after the age the baby is more likely to survive following delivery, when there is no clear evidence of serious onset of labour and the membranes covering the baby are unruptured. Induction of labour may be needed because of a problem in the mother, or her baby or both, and is carried out at or before the ninth (last) month of pregnancy. Obstetricians (specialist caring for pregnant women) have long known that for this to be successful, it is important that the uterine cervix (the neck of the womb) has the favourable characteristics that make it ready to go into the labour. The delivery method and total duration of labour are affected by many factors and cervical readiness (ripeness) is just one of these.
What the research says
Moderate quality evidence was available from the two included studies which compared the Bishop score with transvaginal ultrasound (TVUS) (ultrasound done through the vagina). The studies were considered to be at a low risk of bias. The need for misoprostol (a drug) for softening the cervix (cervical ripening) was more common in the TVUS arm. No clear difference was seen between the two methods in terms of vaginal birth, caesarean delivery, admission of the newborn into the neonatal intensive care unit, meconium staining of the amniotic fluid, abnormal heart beat of the baby within the womb whilst the mother was in labour and Apgar score less than seven (difficulty of the baby establishing life and other life movements on its own immediately after childbirth). None of the included studies reported on tears of the womb or death of the baby just before, during or immediately after childbirth. We did not find any studies that compared Bishop score with any other methods such as the presence of vaginal fetal fibronectin or insulin-like growth factor binding protein-1.
Authors conclusions
Although the overall quality of evidence is moderate, there is no difference in outcomes between the two methods (Bishop score and TVUS) apart from the increased need of misoprostol in the TVUS group. Both methods could be useful to each other, or complementary as the Bishop score does not need any special equipment and uses digital examination which is required to induce labour (to insert a cervical ripening agent, rupture the membranes or separate them from the cervix) but TVUS can give additional information that may affect the course and management of the labour. The choice of a particular method may differ depending on the environment and need since TVUS requires training and may not be readily available and affordable in resource-poor countries.
Future research The two included studies involved a small number of women and further studies are needed. Such studies should include outcomes such as rupture of the womb, perinatal mortality, most appropriate cut-off value for the cervical length and Bishop score to classify women as having ripe or unripe cervices, and cost.
doi:10.1002/14651858.CD010762.pub2
PMCID: PMC4473357  PMID: 26068943
3.  Postpartum consultation: Occurrence, requirements and expectations 
Background
As a matter of routine, midwives in Sweden have spoken with women about their experiences of labour in a so-called 'postpartum consultation'. However, the possibility of offering women this kind of consultation today is reduced due to shortage of both time and resources. The aim of this study was to explore the occurrence, women's requirements of, and experiences of a postpartum consultation, and to identify expectations from women who wanted but did not have a consultation with the midwife assisting during labour.
Methods
All Swedish speaking women who gave birth to a live born child at a University Hospital in western Sweden were consecutively included for a phone interview over a three-week period. An additional phone interview was conducted with the women who did not have a postpartum consultation, but who wanted to talk with the midwife assisting during labour. Data from the interviews were analysed using qualitative content analysis.
Results
Of the 150 interviewed women, 56% (n = 84) had a postpartum consultation of which 61.9% (n = 52) had this with the midwife assisting during labour. Twenty of the 28 women who did not have a consultation with anyone still desired to talk with the midwife assisting during labour. Of these, 19 were interviewed. The content the women wanted to talk about was summarized in four categories: to understand the course of events during labour; to put into words, feelings about undignified management; to describe own behaviour and feelings, and to describe own fear.
Conclusion
The survey shows that the frequency of postpartum consultation is decreasing, that the majority of women who give birth today still require it, but only about half of them receive it. It is crucial to develop a plan for these consultations that meets both the women's needs and the organization within current maternity care.
doi:10.1186/1471-2393-8-29
PMCID: PMC2496898  PMID: 18651967
4.  Exploring Professional Support Offered by Midwives during Labour: An Observation and Interview Study 
Nursing Research and Practice  2012;2012:648405.
Support in labour has an impact on the childbirth experience as well as on childbirth outcomes. Both social and professional support is needed. The aim of this study was to explore professional support offered by midwives during labour in relation to the supportive needs of the childbearing woman and her partner. The study used a qualitative, inductive design using triangulation, with observation followed by interviews. Seven midwives were observed when caring for seven women/couples in labour. After the observations, individual interviews with midwives, women, and their partners were conducted. Data were analysed using hermeneutical text interpretation. The results are presented with three themes. (1) Support as a professional task seems unclear and less well defined than medical controls. (2) Midwives and parents express somewhat different supportive ideas about how to create a sense of security. (3) Partner and midwife interact in support of the childbearing woman. The main interpretation shows that midwives' supportive role during labour could be understood as them mainly adopting the “with institution” ideology in contrast to the “with woman” ideology. This may increase the risk of childbearing women and their partners perceiving lack of support during labour. There is a need to increase efficiency by providing support for professionals to adopt the “with woman” ideology.
doi:10.1155/2012/648405
PMCID: PMC3529493  PMID: 23304482
5.  Continuity of care: what matters to women when they are referred from primary to secondary care during labour? a qualitative interview study in the Netherlands 
Background
Continuity of care during labour is important for women. Women with an intrapartum referral from primary to secondary care look back more negatively on their birh experience compared to those who are not referred. It is not clear which aspects of care contribute to this negative birth experience. This study aimed to explore in-depth the experiences of women who were referred during labour from primary to secondary care with regard to the different aspects of continuity of care.
Methods
A qualitative interview study was conducted in the Netherlands among women who were in primary care at the onset of labour and were referred to secondary care before the baby was born. Through purposive sampling 27 women were selected. Of these, nine women planned their birth at home, two in an alongside midwifery unit and 16 in hospital. Thematic analysis was used.
Results
Continuity of care was a very important issue for women because it contributed to their feeling of safety during labour. Important details were sometimes not handed over between professionals within and between primary and secondary care, in particular about women’s personal preferences. In case of referral of care from primary to secondary care, it was important for women that midwives handed over the care in person and stayed until they felt safe with the hospital team. Personal continuity of care, in which case the midwife stayed until the end of labour, was highly appreciated but not always expected.
Fear of transportion during or after labour was a reason for women to choose hospital birth but also to opt for home birth. Choice of place of birth emerged as a fluid concept; most women planned their place of birth during pregnancy and were aware that they would spend some time at home and possibly some time in hospital.
Conclusions
In case of referral from primary to secondary care during labour, midwives should hand over their care in person and preferrably stay with women throughout labour. Planned place of birth should be regarded as a fluid concept rather than a dichotomous choice.
doi:10.1186/1471-2393-14-103
PMCID: PMC3995441  PMID: 24636135
Continuity of patient care; Home childbirth; Birth experience; Intrapartum care; Primary care
6.  A qualitative descriptive study of the group prenatal care experience: perceptions of women with low-risk pregnancies and their midwives 
Background
Group prenatal care (GPC) originated in 1994 as an innovative model of prenatal care delivery. In GPC, eight to twelve pregnant women of similar gestational age meet with a health care provider to receive their prenatal check-up and education in a group setting. GPC offers significant health benefits in comparison to traditional, one-on-one prenatal care. Women in GPC actively engage in their healthcare and experience a supportive network with one another. The purpose of this study was to better understand the GPC experience of women and care providers in a lower risk group of women than often has been previously studied.
Methods
This qualitative descriptive study collected data through three focus group interviews - two with women who had completed GPC at a midwifery clinic in Ontario, Canada and one with the midwives at the clinic. Data was analyzed through open coding to identify themes.
Results
Nine women and five midwives participated in the focus groups, from which eight categories as well as further subcategories were identified: The women and midwives noted reasons for participating (connections, education, efficiency). Participants suggested both benefits (learning from the group, normalizing the pregnancy experience, preparedness for labour and delivery, and improved relationships as all contributing to positive health outcomes) and concerns with GPC (e.g. sufficient time with the midwife) which generally diminished with experience. Suggestions for change focused on content, environment, partners, and access to the midwives. Challenges to providing GPC included scheduling and systems-level issues such as funding and regulation. Flexibility and commitment to the model facilitated it. Comparison with other models of care identified less of a relationship with the midwife, but more information received. In promoting GPC, women would emphasize the philosophy of care to other women and the midwives would promote the reduction in workload and women’s independence to colleagues.
Conclusions
Overall, women and midwives expressed a high level of satisfaction with their GPC experience. This study gained insight into previously unexplored areas of the GPC experience, perceptions of processes that contribute to positive health outcomes, strategies to promote GPC and elements that enhance the feasibility of GPC.
doi:10.1186/1471-2393-14-334
PMCID: PMC4262064  PMID: 25258167
Group prenatal care; Pregnant women; Midwives; Satisfaction; Experience; Qualitative research
7.  Phase 1 development of an index to measure the quality of neuraxial labour analgesia: exploring the perspectives of childbearing women 
Canadian Journal of Anaesthesia  2010;57(5):468-478.
Purpose
Modern neuraxial labour analgesia reflects a shift in obstetrical anesthesia thinking – away from a simple focus on pain relief towards a focus on the overall quality of analgesia. However, advances in the methods used to measure outcomes have not kept pace with clinical progress, and these approaches must evolve to facilitate meaningful assessment of the advances provided towards the quality of analgesia. Developing a tool to measure the quality of neuraxial labour analgesia that research has achieved is best guided by women’s perspectives. As the initial step in developing an instrument to quantitatively measure quality neuraxial labour analgesia, this qualitative descriptive study explored childbearing women’s experiences and perspectives regarding this subject.
Methods
Twenty-eight postpartum women, all delivering with neuraxial labour analgesia, were recruited from three hospitals in the greater Toronto area. Twenty-five women described a priori plans to use neuraxial labour analgesia, or they described themselves as having been open to the idea. Women’s experiences and perspectives of neuraxial labour analgesia were explored in focus groups and in-depth interviews ≤72 hr following childbirth.
Results
Four major themes emerged: 1)The Enormity of Labour Pain; 2) Fear and Anxiety Related to Epidural Pain Relief; 3) What Women Value about Epidural Pain Relief; and 4) The Relative Value of Achieving Epidural Pain Relief vs Avoidance of Epidural Drug Side Effects. Participants broadly described quality neuraxial labour analgesia as pain relief without side effects. Responses affirmed the importance of traditionally measured outcomes as attributes of quality neuraxial labour analgesia, e.g., pain relief and side effects, as well as the overall importance of pain control during labour and delivery. For research to capture the experience of quality neuraxial labour analgesia, findings suggest that this outcome involves physical, cognitive, and emotional dimensions that must be measured. The findings further suggest an important relationship between each of these dimensions and perceptions of control.
Conclusions
Women’s perspectives must be incorporated into the assessment of quality neuraxial labour analgesia in order for research to measure this outcome in a meaningful manner. Study findings have important implications for scale development, interpretation of existing research, and antenatal education.
doi:10.1007/s12630-010-9289-1
PMCID: PMC2859165  PMID: 20229219
8.  Mobility and maternal position during childbirth in Tanzania: an exploratory study at four government hospitals 
Background
Emerging research evidence suggests a potential benefit in being upright in the first stage of labour and a systematic review of trials suggests both benefits and harmful effects associated with being upright in the second stage of labour. Implementing evidence-based obstetric care in African countries with scarce resources is particularly challenging, and requires an understanding of the cumulative nature of science and commitment to applying the most up to date evidence to clinical decisions. In this study, we documented current practice rates, explored the barriers and opportunities to implementing these procedures from the provider perspective, and documented women's preferences and satisfaction with care.
Methods
This was an exploratory study using quantitative and qualitative methods. Practice rates were determined by exit interviews with a consecutive sample of postnatal women. Provider views were explored using semi-structured interviews (with doctors and traditional birth attendants) and focus group discussions (with midwives). The study was conducted at four government hospitals, two in Dar es Salaam and two in the neighbouring Coast region, Tanzania.
Main outcome measures
Practice rates for mobility during labour and delivery position; women's experiences, preferences and views about the care provided; and provider views of current practice and barriers and opportunities to evidence-based obstetric practice.
Results
Across all study sites more women were mobile at home (15.0%) than in the labour ward (2.9%), but movement was quite restricted at home before women were admitted to labour ward (51.6% chose to rest with little movement). Supine position for delivery was used routinely at all four hospitals; this was consistent with women's preferred choice of position, although very few women are aware of other positions. Qualitative findings suggest obstetricians and midwives favoured confining to bed during the first stage of labour, and supine position for delivery.
Conclusions
The barriers to change appear to be complicated and require providers to want to change, and women to be informed of alternative positions during the first stage of labour and delivery. We believe that highlighting the gap between actual practice and current evidence provides a platform for dialogue with providers to evaluate the threats and opportunities for changing practice.
doi:10.1186/1471-2393-4-3
PMCID: PMC394328  PMID: 15113446
9.  Immersion in water in labour and birth 
Background
Enthusiasts suggest that labouring in water and waterbirth increase maternal relaxation, reduce analgesia requirements and promote a midwifery model of care. Critics cite the risk of neonatal water inhalation and maternal/neonatal infection.
Objectives
To assess the evidence from randomised controlled trials about immersion in water during labour and waterbirth on maternal, fetal, neonatal and caregiver outcomes.
Search methods
We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (30 June 2011) and reference lists of retrieved studies.
Selection criteria
Randomised controlled trials comparing immersion in any bath tub/pool with no immersion, or other non-pharmacological forms of pain management during labour and/or birth, in women during labour who were considered to be at low risk of complications, as defined by the researchers.
Data collection and analysis
We assessed trial eligibility and quality and extracted data independently. One review author entered data and the other checked for accuracy.
Main results
This review includes 12 trials (3243 women): eight related to just the first stage of labour: one to early versus late immersion in the first stage of labour; two to the first and second stages; and another to the second stage only. We identified no trials evaluating different baths/pools, or the management of third stage of labour.
Results for the first stage of labour showed there was a significant reduction in the epidural/spinal/paracervical analgesia/anaesthesia rate amongst women allocated to water immersion compared to controls (478/1254 versus 529/1245; risk ratio (RR) 0.90; 95% confidence interval (CI) 0.82 to 0.99, six trials). There was also a reduction in duration of the first stage of labour (mean difference −32.4 minutes; 95% CI −58.7 to −6.13). There was no difference in assisted vaginal deliveries (RR 0.86; 95% CI 0.71 to 1.05, seven trials), caesarean sections (RR 1.21; 95% CI 0.87 to 1.68, eight trials), use of oxytocin infusion (RR 0.64; 95%CI 0.32 to 1.28,five trials), perineal trauma or maternal infection. There were no differences for Apgar score less than seven at five minutes (RR 1.58; 95% CI 0.63 to 3.93, five trials), neonatal unit admissions (RR 1.06; 95% CI 0.71 to 1.57, three trials), or neonatal infection rates (RR 2.00; 95% CI 0.50 to 7.94, five trials).
Of the three trials that compared water immersion during the second stage with no immersion, one trial showed a significantly higher level of satisfaction with the birth experience (RR 0.24; 95% CI 0.07 to 0.80).
A lack of data for some comparisons prevented robust conclusions. Further research is needed.
Authors’ conclusions
Evidence suggests that water immersion during the first stage of labour reduces the use of epidural/spinal analgesia and duration of the first stage of labour. There is limited information for other outcomes related to water use during the first and second stages of labour, due to intervention and outcome variability. There is no evidence of increased adverse effects to the fetus/neonate or woman from labouring in water or waterbirth. However, the studies are very variable and considerable heterogeneity was detected for some outcomes. Further research is needed.
doi:10.1002/14651858.CD000111.pub3
PMCID: PMC3982045  PMID: 19370552
10.  Births in two different delivery units in the same clinic – A prospective study of healthy primiparous women 
Background
Earlier studies indicate that midwife-led birth settings are associated with modest benefits, including reduced medical interventions and increased maternal satisfaction. The generalizability of these studies to birth settings with low intervention rates, like those generally found in Norway, is not obvious. The aim of the present study was to compare intervention rates associated with labour in low-risk women who begin their labour in a midwife-led unit and a conventional care unit.
Methods
Eligible participants were low-risk primiparas who met the criteria for delivery in the midwife-led ward regardless of which cohort they were allocated to. The two wards are localised at the same floor. Women in both cohorts received the same standardized public antenatal care by general medical practitioners and midwifes who were not involved in the delivery. After admission of a woman to the midwife-led ward, the next woman who met the inclusion criteria, but preferred delivery at the conventional delivery ward, was allocated to the conventional delivery ward cohort. Among the 252 women in the midwife-led ward cohort, 74 (29%) women were transferred to the conventional delivery ward during labour.
Results
Emergency caesarean and instrumental delivery rates in women who were admitted to the midwife-led and conventional birth wards were statistically non-different, but more women admitted to the conventional birth ward had episiotomy. More women in the conventional delivery ward received epidural analgesia, pudental nerve block and nitrous oxide, while more women in the midwife-led ward received opiates and non-pharmacological pain relief.
Conclusion
We did not find evidence that starting delivery in the midwife-led setting offers the advantage of lower operative delivery rates. However, epidural analgesia, pudental nerve block and episiotomies were less often while non-pharmacological pain relief was often used in the midwife-led ward.
doi:10.1186/1471-2393-9-25
PMCID: PMC2712449  PMID: 19545412
11.  Early amniotomy and early oxytocin for prevention of, or therapy for, delay in first stage spontaneous labour compared with routine care 
Background
Caesarean section rates are over 20% in many developed countries. The main diagnosis contributing to the high rate in nulliparae is dystocia or prolonged labour. The present review assesses the effects of a policy of early amniotomy with early oxytocin administration for the prevention of, or the therapy for, delay in labour progress.
Objectives
To estimate the effects of early augmentation with amniotomy and oxytocin for prevention of, or therapy for, delay in labour progress on the caesarean birth rate and on indicators of maternal and neonatal morbidity.
Search methods
We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (15 February 2012), MEDLINE (1966 to 15 February 2012), EMBASE (1980 to 15 February 2012), CINAHL (1982 to 15 February 2012), MIDIRS (1985 to February 2012) and contacted authors for data from unpublished trials.
Selection criteria
Randomized and quasi-randomized controlled trials that compared oxytocin and amniotomy with expectant management.
Data collection and analysis
Three review authors extracted data independently. We stratified the analyses into ’Prevention Trials’ and ’Therapy Trials’ according to the status of the woman at the time of randomization. Participants in the ’Prevention Trials’ were unselected women, without slow progress in labour, who were randomized to a policy of early augmentation or to routine care. In ’Treatment Trials’ women were eligible if they had an established delay in labour progress.
Main results
For this update, we have included a further two new clinical trials. This updated review includes 14 trials, randomizing a total of 8033 women. The unstratified analysis found early intervention with amniotomy and oxytocin to be associated with a modest reduction in the risk of caesarean section; however, the confidence interval (CI) included the null effect (risk ratio (RR) 0.89; 95% CI 0.79 to 1.01; 14 trials; 8033 women). In prevention trials, early augmentation was associated with a modest reduction in the number of caesarean births (RR 0.87; 95% CI 0.77 to 0.99; 11 trials; 7753). A policy of early amniotomy and early oxytocin was associated with a shortened duration of labour (average mean difference (MD) −1.28 hours; 95% CI −1.97 to −0.59; eight trials; 4816 women). Sensitivity analyses excluding four trials with a full package of active management did not substantially affect the point estimate for risk of caesarean section (RR 0.87; 95% CI 0.73 to 1.05; 10 trials; 5165 women). We found no other significant effects for the other indicators of maternal or neonatal morbidity.
Authors’ conclusions
In prevention trials, early intervention with amniotomy and oxytocin appears to be associated with a modest reduction in the rate of caesarean section over standard care.
doi:10.1002/14651858.CD006794.pub3
PMCID: PMC4160792  PMID: 22972098
*Labor Stage, First; Amnion [*surgery]; Cesarean Section [utilization]; Obstetric Labor Complications [prevention & control; *therapy]; Oxytocics [*administration & dosage]; Oxytocin [*administration & dosage]; Randomized Controlled Trials as Topic; Time Factors; Female; Humans; Pregnancy
12.  The association between attendance of midwives and workload of midwives with the mode of birth: secondary analyses in the German healthcare system 
Background
The continuous rise in caesarean rates across most European countries raises multiple concerns. One factor in this development might be the type of care women receive during childbirth. ‘Supportive care during labour’ by midwives could be an important factor for reducing fear, tension and pain and decreasing caesarean rates. The presence and availability of midwives to support a woman in line with her needs are central aspects for ‘supportive care during labour’.
To date, there is no existing research on the influence of effective ‘supportive care’ by German midwives on the mode of birth. This study examines the association between the attendance and workload of midwives with the mode of birth outcomes in a population of low-risk women in a German multicentre sample.
Methods
The data are based on a prospective controlled multicentre trial (n = 1,238) in which the intervention ‘midwife-led care’ was introduced. Four German hospitals participated between 2007 and 2009.
Secondary analyses included a convenience sample of 999 low-risk women from the primary analyses who met the selection criterion ‘low-risk status’. Participation was voluntary. The association between the mode of birth and the key variables ‘attendance of midwives’ and ‘workload of midwives’ was assessed using backward logistic regression models.
Results
The overall rate of spontaneous delivery was 80.7% (n = 763). The ‘attendance of midwives’ and the ‘workload of midwives’ did not exhibit a significant association with the mode of birth. However, women who were not satisfied with the presence of midwives (OR: 2.45, 95% CI 1.54-3.95) or who did not receive supportive procedures by midwives (OR: 3.01, 95% CI 1.50-6.05) were significantly more likely to experience operative delivery or a caesarean. Further explanatory variables include the type of hospital, participation in childbirth preparation class, length of stay from admission to birth, oxytocin usage and parity.
Conclusion
Satisfaction with the presence of and supportive procedures by midwives are associated with the mode of birth. The presence and behaviour of midwives should suit the woman’s expectations and fulfil her needs. For reasons of causality, we would recommend experimental or quasi-experimental research that would exceed the explorative character of this study.
doi:10.1186/1471-2393-14-300
PMCID: PMC4164747  PMID: 25178810
Midwife; Attendance; Workload; One-to-one; Supportive care; Intrapartum care; Continuity; Caesarean; Mode of birth; Operative delivery
13.  BIRTH OUTCOME IN PATIENTS PRESENTING FOR HOSPITAL DELIVERY IN THE SECOND STAGE OF LABOUR  
Abstract
Background: Even though women in labour are expected to be managed in the hospital under the care of an Obstetrician, a subset of women, who actually plan to have hospital delivery spent greater part of their labour at home without any medical assistance and only present to the labour room at full cervical dilatation.
Aim and Objectives: To compare the maternal and neonatal outcome in patients that present in the second stage of labour and those that present in the active phase of labour before full cervical dilatation.
Patients and Methods: This was a prospective case - control study comparing the maternal and neonatal outcomes of women who planned hospital delivery but presented to the labour ward of the University of Maiduguri Teaching Hospital at full cervical dilatation, following an unsupervised first stage at home. For each case, the next two patients that presented for delivery in the active phase of labour were used as controls. The study was conducted between 1st January 2013 to 31st December 2013 and only booked and low risk pregnancies were recruited. Independent sample t-test was used to compare continuous variables. For categorical data, Pearson’s chi-square or Fisher’s exact test was utilized for comparisons. A P value less than 0.05 was considered significant
Results: The incidence of home labour was 11.54% (335/2902). The mean age, gestational age at delivery and birth weights were comparable in the 2 groups with p values of 0.724, 0.787 and 0.618 respectively. However, the parity and the estimated blood loss were significantly higher in the Home labour group compared to the Hospital labour group.
Interventions such as augmentation of labour, episiotomy and caesarean delivery were higher among those that laboured in the hospital compared to those that laboured at home. However, post partum haemorrhage occurred in 6.3% of the Home labour group compared to 0.94% of the Hospital labour group and the differences were statistically significant. The neonatal outcomes were similar in the two groups.
Conclusion:Our finding showed that women that present for hospital delivery in the second stage of labour have increased risk of post partum haemorrhage but the risk of labour augmentation, episiotomy and caesarean delivery is lowered. We advocate that women should be encouraged to present to the labour ward early in labour to avoid hasty delivery and risk post partum haemorrhage.
PMCID: PMC4220473  PMID: 25453020
Home labour; Hospital labour;  Cervical dilatation; ;  Maternal; Neonatal ; Outcome
14.  A case study evaluation of implementation of a care pathway to support normal birth in one English birth centre: anticipated benefits and unintended consequences 
Background
The policy drive for the UK National Health Service (NHS) has focused on the need for high quality services informed by evidence of best practice. The introduction of care pathways and protocols to standardise care and support implementation of evidence into practice has taken place across the NHS with limited evaluation of their impact. A multi-site case study evaluation was undertaken to assess the impact of use of care pathways and protocols on clinicians, service users and service delivery. One of the five sites was a midwifery-led Birth Centre, where an adapted version of the All Wales Clinical Pathway for Normal Birth had been implemented.
Methods
The overarching framework was realistic evaluation. A case study design enabled the capture of data on use of the pathway in the clinical setting, use of multiple methods of data collection and opportunity to study and understand the experiences of clinicians and service users whose care was informed by the pathway. Women attending the Birth Centre were recruited at their 36 week antenatal visit. Episodes of care during labour were observed, following which the woman and the midwife who cared for her were interviewed about use of the pathway. Interviews were also held with other key stakeholders from the study site. Qualitative data were content analysed.
Results
Observations were undertaken of four women during labour. Eighteen interviews were conducted with clinicians and women, including the women whose care was observed and the midwives who cared for them, senior midwifery managers and obstetricians. The implementation of the pathway resulted in a number of anticipated benefits, including increased midwifery confidence in skills to support normal birth and promotion of team working. There were also unintended consequences, including concerns about a lack of documentation of labour care and negative impact on working relationships with obstetric and other midwifery colleagues. Women were unaware their care was informed by a care pathway.
Conclusion
Care pathways are complex interventions which generate a number of consequences for practice. Those considering introduction of pathways need to ensure all relevant stakeholders are engaged with this and develop robust evaluation strategies to accompany implementation.
doi:10.1186/1471-2393-9-47
PMCID: PMC2761848  PMID: 19804624
15.  In the Nepalese context, can a husband’s attendance during childbirth help his wife feel more in control of labour? 
Background
A husband’s support during childbirth is vital to a parturient woman’s emotional well-being. Evidence suggests that this type of support enables a woman to feel more in control during labour by reducing maternal anxiety during childbirth. However, in Nepal, where childbearing is considered an essential element of a marital relationship, the husband’s role in this process has not been explored. Therefore, we examined whether a woman in Nepal feels more in control during labour when her husband is present, compared to when another woman accompanies her or when she has no support person.
Methods
The study participants were low risk primigravida women in the following categories: women who gave birth with their husband present (n = 97), with a female friend present (n = 96), with mixed support (n = 11), and finally, a control group (n = 105). The study was conducted in the public maternity hospital in Kathmandu in 2011. The Labour Agentry Scale (LAS) was used to measure the extent to which women felt in control during labour. The study outcome was compared using an F-test from a one-way analysis of variance, and multiple regression analyses.
Results
The women who gave birth with their husband’s support reported higher mean LAS scores (47.92 ± 6.95) than the women who gave birth with a female friend’s support (39.91 ± 8.27) and the women in the control group (36.68 ± 8.31). The extent to which the women felt in control during labour was found to be positively associated with having their husband’s company during childbirth (β = 0.54; p < 0.001) even after adjusting for background variables. In addition, having a female friend’s company during childbirth was related to the women’s feeling of being in control during labour (β = 0.19; p < 0.001) but the effect size was smaller than for a husband’s company.
Conclusion
The results show that when a woman’s husband is present at the birth, she feels more in control during labour. This finding has strong implications for maternity practices in Nepal, where maternity wards rarely encourage a woman to bring her husband to a pregnancy appointment and to be present during childbirth.
doi:10.1186/1471-2393-12-49
PMCID: PMC3464724  PMID: 22698006
16.  Outcomes of elective induction of labour compared with expectant management: population based study 
Objective To determine neonatal outcomes (perinatal mortality and special care unit admission) and maternal outcomes (mode of delivery, delivery complications) of elective induction of labour compared with expectant management.
Design Retrospective cohort study using an unselected population database.
Setting Consultant and midwife led obstetric units in Scotland 1981-2007.
Participants 1 271 549 women with singleton pregnancies of 37 weeks or more gestation.
Interventions Outcomes of elective induction of labour (induction of labour with no recognised medical indication) at 37, 38, 39, 40, and 41 weeks’ gestation compared with those of expectant management (continuation of pregnancy to either spontaneous labour, induction of labour or caesarean section at a later gestation).
Main outcome measures Extended perinatal mortality, mode of delivery, postpartum haemorrhage, obstetric anal sphincter injury, and admission to a neonatal or special care baby unit. Outcomes were adjusted for age at delivery, parity, year of birth, birth weight, deprivation category, and, where appropriate, mode of delivery.
Results At each gestation between 37 and 41 completed weeks, elective induction of labour was associated with a decreased odds of perinatal mortality compared with expectant management (at 40 weeks’ gestation 0.08% (37/44 764) in the induction of labour group versus 0.18% (627/350 643) in the expectant management group; adjusted odds ratio 0.39, 99% confidence interval 0.24 to 0.63), without a reduction in the odds of spontaneous vertex delivery (at 40 weeks’ gestation 79.9% (35 775/44 778) in the induction of labour group versus 73.7% (258 665/350 791) in the expectant management group; adjusted odds ratio 1.26, 1.22 to 1.31). Admission to a neonatal unit was, however, increased in association with elective induction of labour at all gestations before 41 weeks (at 40 weeks’ gestation 8.0% (3605/44 778) in the induction of labour group compared with 7.3% (25 572/350 791) in the expectant management group; adjusted odds ratio 1.14, 1.09 to 1.20).
Conclusion Although residual confounding may remain, our findings indicate that elective induction of labour at term gestation can reduce perinatal mortality in developed countries without increasing the risk of operative delivery.
doi:10.1136/bmj.e2838
PMCID: PMC3349781  PMID: 22577197
17.  Knowledge, attitudes and use of labour analgesia among women at a low-income country antenatal clinic 
BMC Anesthesiology  2015;15:98.
Background
Childbirth is one of the most painful experiences of a woman’s life. Authorities in the fields of obstetrics and anaesthesia encourage use of labour analgesia. Unlike in high-income countries, pain relief in labour in Africa is not a well established service, especially in the low-income countries like Uganda. Little is known about whether parturients would be amenable to labour analgesia. We sought to determine knowledge, attitudes and use of labour analgesia among women attending the antenatal clinic at Mulago National Referral Hospital.
Methods
Upon obtaining institutional approval, we conducted a cross-sectional descriptive study. Women were requested to complete the researcher-administered survey following informed consent. The study was conducted in the general antenatal clinic at the Mulago National Referral Hospital.
Results
Of 1293 participants interviewed, only 7 % of the participants had knowledge of labour analgesia. Of the multiparous mothers 87.9 % did not have labour analgesia in their previous deliveries, although 79.2 % of them had delivered in a national referral hospital. The commonest reason for refusal of labour analgesia was to experience natural childbirth. 87.7 % of the participants wanted labour analgesia for their next delivery.
Conclusion
There is a wide gap between the desire for labour analgesia and its availability. Obstetricians and anaesthesiologists have a role to educate the women, and to provide this much desired service.
doi:10.1186/s12871-015-0078-9
PMCID: PMC4492001  PMID: 26148501
Labour Analgesia; Perceptions; Low-and-middle income country; Uganda
18.  Birth setting, transfer and maternal sense of control: results from the DELIVER study 
Background
In the Netherlands, low risk women receive midwife-led care and can choose to give birth at home or in hospital. There is concern that transfer of care during labour from midwife-led care to an obstetrician-led unit leads to negative birth experiences, in particular among those with planned home birth. In this study we compared sense of control, which is a major attribute of the childbirth experience, for women planning home compared to women planning hospital birth under midwife-led care. In particular, we studied sense of control among women who were transferred to obstetric-led care during labour according to planned place of birth: home versus hospital.
Methods
We used data from the prospective multicentre DELIVER (Data EersteLIjns VERloskunde) cohort-study, conducted in 2009 and 2010 in the Netherlands. Sense of control during labour was assessed 6 weeks after birth, using the short version of the Labour Agentry Scale (LAS-11). A higher LAS-11 score indicates a higher feeling of control. We considered a difference of a minimum of 5.5 points as clinically relevant.
Results
Nulliparous- and parous women who planned a home birth had a 2.6 (95% CI 1.0, 4.3) and a 3.0 (1.6, 4.4) higher LAS score during first stage of labour respectively and during second stage a higher score of 2.8 (0.9, 4.7) and 2.3 (0.6, 4.0), compared with women who planned a hospital birth. Overall, women who were transferred experienced a lower sense of control than women who were not transferred. Parous women who planned a home birth and who were transferred had a 4.3 (0.2, 8.4) higher LAS score in 2nd stage, compared to those who planned a hospital birth and who were transferred.
Conclusion
We found no clinically relevant differences in feelings of control among women who planned a home or hospital birth. Transfer of care during labour lowered feelings of control, but feelings of control were similar for transferred women who planned a home or hospital birth.
As far as their expected sense of control is concerned, low risk women should be encouraged to give birth at the location of their preference.
doi:10.1186/1471-2393-14-27
PMCID: PMC3898490  PMID: 24438469
19.  Different methods for the induction of labour in outpatient settings 
Background
Induction of labour is carried out for a variety of indications and using a range of pharmacological, mechanical and other methods. For women at low risk, some methods of induction of labour may be suitable for use in outpatient settings.
Objectives
To examine pharmacological and mechanical interventions to induce labour in outpatient settings in terms of feasibility, effectiveness, maternal satisfaction, healthcare costs and, where information is available, safety. The review complements existing reviews on labour induction examining effectiveness and safety.
Search methods
We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (December 2009) and reference lists of retrieved studies.
Selection criteria
We included randomised controlled trials examining outpatient cervical ripening or induction of labour with pharmacological agents or mechanical methods.
Data collection and analysis
Two authors independently extracted data and assessed eligible papers for risk of bias. We checked all data after entry into review manager software.
Main results
We included 28 studies with 2616 women examining different methods of induction of labour where women received treatment at home or were sent home after initial treatment and monitoring in hospital.
Studies examined vaginal and intracervical PGE2, vaginal and oral misoprostol, isosorbide mononitrate, mifepristone, oestrogens, and acupuncture. Overall, the results demonstrate that outpatient induction of labour is feasible and that important adverse events are rare. There was no strong evidence that agents used to induce labour in outpatient settings had an impact (positive or negative) on maternal or neonatal health. There was some evidence that, compared to placebo or no treatment, induction agents reduced the need for further interventions to induce labour, and shortened the interval from intervention to birth. We were unable to pool results on outcomes relating to progress in labour as studies tended to measure a very broad range of outcomes.
There was no evidence that induction agents increased interventions in labour such as operative deliveries. Only two studies provided information on women’s views about the induction process, and overall there was very little information on the costs to health service providers of different methods of labour induction in outpatient settings.
Authors’ conclusions
Induction of labour in outpatient settings appears feasible. We do not have sufficient evidence to know which induction methods are preferred by women, or the interventions that are most effective and safe to use in outpatient settings.
doi:10.1002/14651858.CD007701.pub2
PMCID: PMC4241469  PMID: 20687092
* Ambulatory Care; Acupuncture Therapy [methods]; Feasibility Studies; Labor, Induced [* methods]; Oxytocics; Randomized Controlled Trials as Topic; Female; Humans; Pregnancy
20.  Waiting for attention and care: birthing accounts of women in rural Tanzania who developed obstetric fistula as an outcome of labour 
Background
Obstetric fistula is a physically and socially disabling obstetric complication that affects about 3,000 women in Tanzania every year. The fistula, an opening that forms between the vagina and the bladder and/or the rectum, is most frequently caused by unattended prolonged labour, often associated with delays in seeking and receiving appropriate and adequate birth care. Using the availability, accessibility, acceptability and quality of care (AAAQ) concept and the three delays model, this article provides empirical knowledge on birth care experiences of women who developed fistula after prolonged labour.
Methods
We used a mixed methods approach to explore the birthing experiences of women affected by fistula and the barriers to access adequate care during labour and delivery. Sixteen women were interviewed for the qualitative study and 151 women were included in the quantitative survey. All women were interviewed at the Comprehensive Community Based Rehabilitation Tanzania in Dar es Salaam and Bugando Medical Centre in Mwanza.
Results
Women experienced delays both before and after arriving at a health facility. Decisions on where to seek care were most often taken by husbands and mothers-in-law (60%). Access to health facilities providing emergency obstetric care was inadequate and transport was a major obstacle. About 20% reported that they had walked or were carried to the health facility. More than 50% had reported to a health facility after two or more days of labour at home. After arrival at a health facility women experienced lack of supportive care, neglect, poor assessment of labour and lack of supervision. Their birth accounts suggest unskilled birth care and poor referral routines.
Conclusions
This study reveals major gaps in access to and provision of emergency obstetric care. It illustrates how poor quality of care at health facilities contributes to delays that lead to severe birth injuries, highlighting the need to ensure women's rights to accessible, acceptable and adequate quality services during labour and delivery.
doi:10.1186/1471-2393-11-75
PMCID: PMC3221614  PMID: 22013991
21.  Measuring the quality and quantity of professional intrapartum support: testing a computerised systematic observation tool in the clinical setting 
Background
Continuous support in labour has a significant impact on a range of clinical outcomes, though whether the quality and quantity of support behaviours affects the strength of this impact has not yet been established. To identify the quality and quantity of support, a reliable means of measurement is needed. To this end, a new computerised systematic observation tool, the ‘SMILI’ (Supportive Midwifery in Labour Instrument) was developed.
The aim of the study was to test the validity and usability of the ‘Supportive Midwifery in Labour Instrument’ (SMILI) and to test the feasibility and acceptability of the systematic observation approach in the clinical intrapartum setting.
Methods
Systematic observation was combined with a postnatal questionnaire and the collection of data about clinical processes and outcomes for each observed labour.
The setting for the study was four National Health Service maternity units in Scotland, UK. Participants in this study were forty five midwives and forty four women.
The SMILI was used by trained midwife observers to record labour care provided by midwives. Observations were undertaken for an average of two hours and seventeen minutes during the active first stage of labour and, in 18 cases, the observation included the second stage of labour. Content validity of the instrument was tested by the observers, noting the extent to which the SMILI facilitated the recording of all key aspects of labour care and interactions. Construct validity was tested through exploration of correlations between the data recorded and women’s feelings about the support they received. Feasibility and usability data were recorded following each observation by the observer. Internal reliability and construct validity were tested through statistical analysis of the data.
Results
One hundred and four hours of labour care were observed and recorded using the SMILI during forty nine labour episodes.
Conclusion
The SMILI was found to be a valid and reliable instrument in the intrapartum setting in which it was tested. The study identified that the SMILI could be used to test correlations between the quantity and quality of support and outcomes. The systematic observational approach was found to be an acceptable and feasible method of enquiry.
doi:10.1186/1471-2393-13-163
PMCID: PMC3751507  PMID: 23945049
Intrapartum; Labour; Support; Midwife; Systematic; Observation; Quantity; Quality; Clinical outcomes
22.  Effect of food intake during labour on obstetric outcome: randomised controlled trial 
Objective To investigate the effect of feeding during labour on obstetric and neonatal outcomes.
Design Prospective randomised controlled trial.
Setting Birth centre in London teaching hospital.
Participants 2426 nulliparous, non-diabetic women at term, with a singleton cephalic presenting fetus and in labour with a cervical dilatation of less than 6 cm.
Intervention Consumption of a light diet or water during labour.
Main outcome measures The primary outcome measure was spontaneous vaginal delivery rate. Other outcomes measured included duration of labour, need for augmentation of labour, instrumental and caesarean delivery rates, incidence of vomiting, and neonatal outcome.
Results The spontaneous vaginal delivery rate was the same in both groups (44%; relative risk 0.99, 95% confidence interval 0.90 to 1.08). No clinically important differences were found in the duration of labour (geometric mean: eating, 597 min v water, 612 min; ratio of geometric means 0.98, 95% confidence interval 0.93 to 1.03), the caesarean delivery rate (30% v 30%; relative risk 0.99, 0.87 to 1.12), or the incidence of vomiting (35% v 34%; relative risk 1.05, 0.9 to 1.2). Neonatal outcomes were also similar.
Conclusions Consumption of a light diet during labour did not influence obstetric or neonatal outcomes in participants, nor did it increase the incidence of vomiting. Women who are allowed to eat in labour have similar lengths of labour and operative delivery rates to those allowed water only.
Trial registration Current Controlled Trials ISRCTN33298015.
doi:10.1136/bmj.b784
PMCID: PMC2660391  PMID: 19318702
23.  The Impact of Labour Epidural Analgesia on the Childbirth Expectation and Experience at a Tertiary Care Center in Southern India. 
Background: Labour epidural analgesia is increasingly used as a means of pain relief for women during labour and delivery. The significant pain during labour and delivery can be terrifying for mothers-to-be and the prospect of relief from pain can help reduce fear of childbirth to an extent. However, it is not necessary that reduced fear of childbirth may lead to an increased satisfaction with the childbirth experience.
Aim: To determine the influence of labour epidural analgesia (LEA) on the experience of childbirth in pregnant women at a tertiary care center in southern India
Materials and Methods: A pre-post interventional non-randomized study design at a tertiary care perinatal institute that used the Wijma Delivery Expectation and Experience questionnaires to determine baseline expectations of labour and childbirth and the actual experience in pregnant women. Labour analgesia was provided on maternal request or demand. Total and domain scores were compared between the two groups using non-parametric tests and a generalized linear repeated measures model after adjusting for factors that were found significant in the bivariate model.
Results: The study included 235 pregnant women who opted for LEA and 219 pregnant women who opted against LEA. Overall, 37 (15.74%) of woman with LEA and 30 (13.70%) of women without LEA had a worse than expected experience of childbirth. Significant pain relief (p<0.001) was provided with LEA, however, the post-delivery scores did not differ significantly between the two groups (F=0.90, p=0.34) in a generalized linear repeated measures model.
Conclusion: Maternal satisfaction with the process of childbirth is a complex dynamic that is not limited to the significant relief from pain provided by LEA.
doi:10.7860/JCDR/2014/8039.4111
PMCID: PMC4003692  PMID: 24783086
Maternal satisfaction; Labour epidural analgesia; Pain relief; Childbirth; Delivery
24.  The pathway of obstructed labour as perceived by communities in south-western Uganda: a grounded theory study 
Global Health Action  2011;4:10.3402/gha.v4i0.8529.
Background
Obstructed labour is still a major cause of maternal and perinatal morbidity and mortality in Uganda, where many women give birth at home alone or assisted by non-skilled birth attendants. Little is known of how the community view obstructed labour, and what actions they take in cases where this complication occurs.
Objective
The objective of the study was to explore community members’ understanding of and actions taken in cases of obstructed labour in south-western Uganda.
Design
Grounded theory (GT) was used to analyse data from 20 focus group discussions (FGDs), 10 with women and 10 with men, which were conducted in eight rural and two urban communities.
Results
A conceptual model based on the community members’ understanding of obstructed labour and actions taken in response is presented as a pathway initiated by women's desire to ‘protecting own integrity’ (core category). The pathway consisted of six other categories closely linked to the core category, namely: (1) ‘taking control of own birth process’; (2) ‘reaching the limit – failing to give birth’ (individual level); (3) ‘exhausting traditional options’; (4) ‘partner taking charge’; (5) ‘facing challenging referral conditions’ (community level); and finally (6) ‘enduring a non-responsive healthcare system’ (healthcare system level).
Conclusions
There is a need to understand and acknowledge women's reluctance to involve others during childbirth. However, the healthcare system should provide acceptable care and a functional referral system closer to the community, thus supporting the community's ability to seek timely care as a response to obstructed labour. Easy access to mobile phones may improve referral systems. Upgrading of infrastructure in the region requires a multi-sectoral approach. Testing of the conceptual model through a quantitative questionnaire is recommended.
doi:10.3402/gha.v4i0.8529
PMCID: PMC3248029  PMID: 22216018
obstructed labour; community members; understanding; actions; protecting own integrity; Uganda; Africa; maternal mortality; childbirth; delivery care; mobile phones; transport
25.  Uterine Rupture by Intended Mode of Delivery in the UK: A National Case-Control Study 
PLoS Medicine  2012;9(3):e1001184.
A case-control study using UK data estimates the risk of uterine rupture in subsequent deliveries amongst women who have had a previous caesarean section.
Background
Recent reports of the risk of morbidity due to uterine rupture are thought to have contributed in some countries to a decrease in the number of women attempting a vaginal birth after caesarean section. The aims of this study were to estimate the incidence of true uterine rupture in the UK and to investigate and quantify the associated risk factors and outcomes, on the basis of intended mode of delivery.
Methods and Findings
A UK national case-control study was undertaken between April 2009 and April 2010. The participants comprised 159 women with uterine rupture and 448 control women with a previous caesarean delivery. The estimated incidence of uterine rupture was 0.2 per 1,000 maternities overall; 2.1 and 0.3 per 1,000 maternities in women with a previous caesarean delivery planning vaginal or elective caesarean delivery, respectively. Amongst women with a previous caesarean delivery, odds of rupture were also increased in women who had ≥ two previous caesarean deliveries (adjusted odds ratio [aOR] 3.02, 95% CI 1.16–7.85) and <12 months since their last caesarean delivery (aOR 3.12, 95% CI 1.62–6.02). A higher risk of rupture with labour induction and oxytocin use was apparent (aOR 3.92, 95% CI 1.00–15.33). Two women with uterine rupture died (case fatality 1.3%, 95% CI 0.2–4.5%). There were 18 perinatal deaths associated with uterine rupture among 145 infants (perinatal mortality 124 per 1,000 total births, 95% CI 75–189).
Conclusions
Although uterine rupture is associated with significant mortality and morbidity, even amongst women with a previous caesarean section planning a vaginal delivery, it is a rare occurrence. For women with a previous caesarean section, risk of uterine rupture increases with number of previous caesarean deliveries, a short interval since the last caesarean section, and labour induction and/or augmentation. These factors should be considered when counselling and managing the labour of women with a previous caesarean section.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Uterine rupture is a serious complication of pregnancy in which the wall of the uterus (womb) tears during pregnancy or early labor. Signs and symptoms of uterine rupture include fetal heart rate abnormalities, abdominal pain, and vaginal bleeding. If uterine rupture happens during labor, the woman must have an immediate caesarean section (surgical delivery of her baby) to save both her life and that of her baby. The woman's womb and nearby organs can be damaged at rupture or removed during surgery and she may need a blood transfusion because of severe bleeding. Moreover, her baby may develop respiratory distress syndrome and other life-threatening complications. In high income countries, uterine rupture most commonly occurs in women who have delivered a previous pregnancy by caesarean section. In a caesarean section, the baby is delivered through a cut made through the abdominal wall and the uterine wall. The stretching that occurs during pregnancy or the strong contractions of labor can tear the scar left by this cut, resulting in uterine rupture.
Why Was This Study Done?
Women who have had a caesarean delivery are generally encouraged to try to deliver subsequent babies vaginally. However, recent reports of an increased risk of complications (morbidity) and death (mortality) due to uterine rupture are thought to reduce women's willingness to attempt vaginal birth after caesarean (VBAC) in some countries. In the UK, for example, where one in four babies is delivered by caesarean section, a previous caesarean delivery is one of commonest reasons for a repeat section. Obstetricians (doctors who care for women during child birth) need to know as much as possible about the incidence of uterine rupture and about the risk factors for it so that they can advise women who have had a previous caesarean section about their delivery options. In this national case-control study (a study that compares the characteristics of people with and without a specific condition), the researchers estimate the incidence of uterine rupture in the UK by intended mode of delivery and investigate and quantify the risk factors for and outcomes of uterine rupture.
What Did the Researchers Do and Find?
The researchers used the UK Obstetric Surveillance System (UKOSS) to identify all the women in the UK who had a uterine rupture over a 13-month period (159 women, 139 of whom had had a previous caesarean delivery). Controls for the study were women who had not had a uterine rupture but who had previously delivered by caesarean section. Overall, the incidence of uterine rupture was 0.2 per 1,000 maternities. In women with a previous caesarean delivery, 2.1 and 0.3 per 1,000 maternities ended in uterine rupture in women planning vaginal delivery and caesarean delivery, respectively. Amongst women who had had a previous caesarean delivery, the risk of uterine rupture was greater among those who had had two or more previous caesarean deliveries or a caesarean delivery less than 12 months previously, or whose labor was induced. Two women died following uterine rupture (a case fatality of 1.3%) and 18 babies died around the time of birth (a perinatal mortality rate of 124 per 1,000 live births; the UK perinatal mortality rate is 7.5 per 1,000 live births). 15 of the women who had a uterine rupture had their womb removed, 10 had other organs damaged, and nearly half had other complications; 19 of the surviving babies had health problems.
What Do These Findings Mean?
These findings indicate that, in the UK, although uterine rupture is associated with significant mortality and morbidity, it is a rare occurrence even among women who have had a previous caesarean delivery and are planning a vaginal delivery. They also indicate that, for women who have previously had a caesarean section, the risk of rupture increases with the number of previous caesarean deliveries, with a short interval since the last caesarean section, and with labor induction. Although the researchers may not have identified all the women who had a uterine rupture during the study period or may have identified only the worst cases, these findings provide valuable information about the factors that obstetricians need to consider when advising women who have previously had a caesarean section and when managing their labor.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001184.
This study is linked to a PLoS Medicine Research Article by Caroline Crowther and a PLoS Medicine Perspective by Catherine Spong
Wikipedia has a page on uterine rupture (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The American Congress of Obstetricians and Gynecologists has information sheets for patients on caesarean sections and on vaginal birth after caesarean delivery
The Royal College of Obstetricians and Gynaecologists in the UK has information for women on birth after previous caesarean
Childbirth Connection, a US-based not-for-profit organization, provides information about caesarean sections and about vaginal birth after caesarean
The National Childbirth Trust, a UK charity, provides information for parents on all aspects of pregnancy and birth, including caesarean sections and vaginal birth after caesarean delivery
The UK charity Healthtalkonline has personal stories from women making decisions about birth after a caesarean section
A personal story of uterine rupture during an attempted VBAC is available
The UK Obstetric Surveillance System studies rare disorders of pregnancy in the UK
doi:10.1371/journal.pmed.1001184
PMCID: PMC3302846  PMID: 22427745

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