Objectives To evaluate the impact of labouring in water during first stage of labour on rates of epidural analgesia and operative delivery in nulliparous women with dystocia.
Design Randomised controlled trial.
Setting University teaching hospital in southern England.
Participants 99 nulliparous women with dystocia (cervical dilation rate < 1 cm/hour in active labour) at low risk of complications.
Interventions Immersion in water in birth pool or standard augmentation for dystocia (amniotomy and intravenous oxytocin).
Main outcome measures Primary: epidural analgesia and operative delivery rates. Secondary: augmentation rates with amniotomy and oxytocin, length of labour, maternal and neonatal morbidity including infections, maternal pain score, and maternal satisfaction with care.
Results Women randomised to immersion in water had a lower rate of epidural analgesia than women allocated to augmentation (47% v 66%, relative risk 0.71 (95% confidence interval 0.49 to 1.01), number needed to treat for benefit (NNT) 5). They showed no difference in rates of operative delivery (49% v 50%, 0.98 (0.65 to 1.47), NNT 98), but significantly fewer received augmentation (71% v 96%, 0.74 (0.59 to 0.88), NNT 4) or any form of obstetric intervention (amniotomy, oxytocin, epidural, or operative delivery) (80% v 98%, 0.81 (0.67 to 0.92), NNT 5). More neonates of women in the water group were admitted to the neonatal unit (6 v 0, P = 0.013), but there was no difference in Apgar score, infection rates, or umbilical cord pH.
Conclusions Labouring in water under midwifery care may be an option for slow progress in labour, reducing the need for obstetric intervention, and offering an alternative pain management strategy.
This study was undertaken to investigate women's accounts of interactions with health care providers during labour and delivery and to assess the implications for acceptability and utilisation of maternity services in Ghana.
Twenty-one individual in-depth interviews and two focus group discussions were conducted with women of reproductive age who had delivered in the past five years in the Greater Accra Region. The study investigated women's perceptions and experiences of care in terms of factors that influenced place of delivery, satisfaction with services, expectations of care and whether they would recommend services.
One component of care which appeared to be of great importance to women was staff attitudes. This factor had considerable influence on acceptability and utilisation of services. Otherwise, a successful labour outcome and non-medical factors such as cost, perceived quality of care and proximity of services were important. Our findings indicate that women expect humane, professional and courteous treatment from health professionals and a reasonable standard of physical environment. Women will consciously change their place of delivery and recommendations to others if they experience degrading and unacceptable behaviour.
The findings suggest that inter-personal aspects of care are key to women's expectations, which in turn govern satisfaction. Service improvements which address this aspect of care are likely to have an impact on health seeking behaviour and utilisation. Our findings suggest that user-views are important and warrant further investigation. The views of providers should also be investigated to identify channels by which service improvements, taking into account women's views, could be operationalised. We also recommend that interventions to improve delivery care should not only be directed to the health professional, but also to general health system improvements.
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.
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.
Guidelines recommend supportive care for all newborns >26 weeks’ gestational age and recognize the importance of prenatal consultation by a neonatalogist for mothers at risk of premature delivery. These recommendations are drawn from medical expert opinions and emphasize informing parents about prematurity. The literature regarding parents’ perspectives of prenatal consultation is lacking.
To explore mothers’ concerns about preterm labour and their expectations from the prenatal consultation with a neonatologist.
Interviews of women hospitalized for preterm labour (26 to 32 weeks’ gestation) were conducted before they met with the neonatologist. The analysis was informed by grounded theory.
The women’s stressful experience was their main focus; they expressed a strong sense of loss of control and powerlessness. The consultation was perceived as an added source of stress, but they all hoped that it would reassure them. They wanted information about prematurity and the roles they would play for their baby. They expected the neonatologist to be supportive, open and trustworthy.
Prenatal consultation is perceived as a source of both stress and reassurance. Women believe the latter can be achieved through a supportive consultation with the neonatologist, during which tools providing them with a sense of empowerment are presented.
Autonomy; Bioethics; Informed consent; Neonatology; Prenatal consultation
Objective To obtain the views of women on the impact of operative delivery in the second stage of labour.
Design Qualitative interview study.
Setting Two urban teaching hospitals in the United Kingdom.
Participants Purposive sample of 27 women who had undergone operative delivery in the second stage of labour between January 2000 and January 2002.
Key themes Preparation for birth, understandings of the indications for operative delivery, and explanation or debriefing after birth.
Results The women felt unprepared for operative delivery and thought that their birth plan or antenatal classes had not catered adequately for this event. They emphasised the importance of maintaining an open mind about the management of labour. They had difficulty understanding the need for operative delivery despite a review by medical and midwifery staff before discharge. Operative delivery had a noticeable impact on women's views about future pregnancy and delivery.
Conclusions Women consider postnatal debriefing and medical review important deficiencies in current care. Those who experienced operative delivery in the second stage of labour would welcome the opportunity to have a later review of their intrapartum care, physical recovery, and management of future pregnancies.
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.
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.
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.
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.
Midwifery units offer care to women with straightforward pregnancies, but unforeseen complications can arise during labour or soon after birth, necessitating transfer to a hospital obstetric unit. In England, 21% of women planning birth in freestanding midwifery units are transferred; in alongside units, the transfer rate is 26%. There is little high quality contemporary evidence on women’s experience of transfer.
We carried out a qualitative interview study, using semi-structured interviews, with women who had been transferred from a midwifery unit (freestanding or alongside) in England up to 12 months prior to interview. Maximum variation sampling was used. Interviews with 30 women took place between March 2009 and March 2010. Thematic analysis using constant comparison and exploration of deviant cases was carried out.
Most women hoped for or expected a natural birth and did not expect to be transferred. Transfer was disappointing for many; sensitive and supportive care and preparation for the need for transfer helped women adjust to their changing circumstances. A small number of women, often in the context of prolonged labour, described transfer as a relief. For women transferred from freestanding units, the ambulance journey was a “limbo” period. Women wondered, worried or were fearful about what was to come and could be passive participants who felt like they were being “transported” rather than cared for. For many this was a direct contrast with the care they experienced in the midwifery unit. After transfer, most women appreciated the opportunity to talk about their experience to make sense of what happened and help them plan for future pregnancies, but did not necessarily seek this out if it was not offered.
Transfer affects a significant minority of women planning birth in midwifery units and is therefore a concern for women and midwives. Transfer is not expected by women, but sensitive care and preparation can help women adjust to changing circumstances. Particular sensitivity around decision-making may be required by midwives caring for women during prolonged labour. Some apparently straightforward changes to practice have the potential to make an important difference to women’s experience of ambulance transfer.
Midwifery units; Birth centres; Intrapartum care; Transfer; Qualitative research
Dystocia, difficult labour, is a common but also complex problem during childbirth. It can be attributed to either weak contractions of the uterus, a large infant, reduced capacity of the pelvis or combinations of these. Previous studies have indicated that there is a genetic component in the susceptibility of experiencing dystocia. The purpose of this study was to identify susceptibility genes in dystocia.
A total of 104 women in 47 families were included where at least two sisters had undergone caesarean section at a gestational length of 286 days or more at their first delivery. Study of medical records and a telephone interview was performed to identify subjects with dystocia. Whole-genome scanning using Affymetrix genotyping-arrays and non-parametric linkage (NPL) analysis was made in 39 women exhibiting the phenotype of dystocia from 19 families. In 68 women re-sequencing was performed of candidate genes showing suggestive linkage: oxytocin (OXT) on chromosome 20 and oxytocin-receptor (OXTR) on chromosome 3.
We found a trend towards linkage with suggestive NPL-score (3.15) on chromosome 12p12. Suggestive linkage peaks were observed on chromosomes 3, 4, 6, 10, 20. Re-sequencing of OXT and OXTR did not reveal any causal variants.
Dystocia is likely to have a genetic component with variations in multiple genes affecting the patient outcome. We found 6 loci that could be re-evaluated in larger patient cohorts.
In nulliparous women dystocia is the most common obstetric problem and its etiology is largely unknown. The frequency of augmentation and cesarean delivery related to dystocia is high although it is not clear if a slow progress justifies the interventions. Studies of risk factors for dystocia often do not provide diagnostic criteria for the diagnosis. The aim of the present study was to identify obstetric and clinical risk indicators of dystocia defined by strict and explicit criteria.
A multi-centre population based cohort study with prospectively collected data from 2810 nulliparous women in term spontaneous labour with a singleton infant in cephalic presentation. Data were collected by self-administered questionnaires and clinical data-records. Logistic regression analyses were used to estimate adjusted Odds Ratios (OR) and 95% confidence intervals (CI) are given.
The following characteristics, present at admission to hospital, were associated with dystocia during labour (OR, 95% CI): dilatation of cervix < 4 cm (1.63, 1.38–1.92), tense cervix (1.31, 1.04–1.65), thick lower segment (1.32, 1.09–1.61), fetal head above the inter-spinal diameter (2.29, 1.80–2.92) and poor fetal head-to-cervix contact (1.83, 1.31–2.56). The use of epidural analgesia (5.65, 4.33–7.38) was also associated with dystocia.
Vaginal examinations at admission provide useful information on risk indicators for dystocia. The strongest risk indicator was use of epidural analgesia and if part of that is causal, it is of concern.
To investigate the effect of maternal obesity on mode of delivery following induction of labour (IOL) for prolonged pregnancy and subsequent intrapartum and neonatal complications.
Retrospective (historical) cohort study.
Liverpool Women's Hospital NHS Foundation Trust, UK.
A total of 29 224 women with singleton pregnancies between 2004 and 2008 of whom 3076 had a prolonged pregnancy (defined as ≥290 days or 41+3 weeks of gestation) and received IOL.
Kruskal–Wallis test, chi-square test and multivariable logistic regression.
Main outcome measures
Mode of delivery and risk of delivery and neonatal complications in obese verses non-obese women following IOL.
Obese women had a significantly higher rate of IOL ending in caesarean section compared with women of normal weight following IOL (38.7% versus 23.8% primiparous; 9.9% versus 7.9% multiparous women, respectively); however, length of labour, incidence of postpartum haemorrhage and third-degree tear, rate of low cord blood pH, low Apgar scores and shoulder dystocia were similar in all body mass index categories. Complications included a higher incidence of fetal macrosomia and second-degree, but not third-degree, tear in primiparous women.
Higher maternal body mass index at booking is associated with an increased risk of prolonged pregnancy and increased rate of IOL. Despite this, more than 60% of obese primiparous and 90% of multiparous women with prolonged pregnancies who were induced achieved vaginal delivery and labour complications in the obese women with prolonged pregnancies were largely comparable to those of normal weight women with prolonged pregnancies. Our data suggest that IOL for prolonged pregnancy in obese women is a reasonable and safe management option.
Body mass index; induction of labour; labour complications; obesity; prolonged pregnancy
The labour stencil representing the expected cervimetric progress of normal labour was used in 741 consecutive spontaneous labours to identify high-risk labours which needed oxytocic stimulation. Uterine contractions were stimulated if progress extended two hours past the nomogram, which resulted in shorter labours, fewer instrumental deliveries and caesarean sections, and babies with higher Apgar scores than in those dysfunctional labours which were not stimulated. According to the protocol used 36% of primigravid and 13% of multigravid labours needed acceleration. The remaining patients did not need any oxytocic interference during the first stage. This selection of patients is important to prevent a major obstetric advance being abused and discredited at a time when the profession and public are questioning the safety of active labour.
Introduction. Results from previous studies on acupuncture for labour pain are contradictory and lack important information on methodology. However, studies indicate that acupuncture has a positive effect on women's experiences of labour pain. The aim of the present study was to evaluate the efficacy of two different acupuncture stimulations, manual or electrical stimulation, compared with standard care in the relief of labour pain as the primary outcome. This paper will present in-depth information on the design of the study, following the CONSORT and STRICTA recommendations. Methods. The study was designed as a randomized controlled trial based on western medical theories. Nulliparous women with normal pregnancies admitted to the delivery ward after a spontaneous onset of labour were randomly allocated into one of three groups: manual acupuncture, electroacupuncture, or standard care. Sample size calculation gave 101 women in each group, including a total of 303 women. A Visual Analogue Scale was used for assessing pain every 30 minutes for five hours and thereafter every hour until birth. Questionnaires were distributed before treatment, directly after the birth, and at one day and two months postpartum. Blood samples were collected before and after the first treatment. This trial is registered at ClinicalTrials.gov: NCT01197950.
The amount of pain that had been experienced by 1000 women during vaginal delivery of a live child was determined by interview within 48 hours of delivery. Patients had been offered a choice of analgesia, and 536 had received epidural analgesia: pain relief was greatest in this group, just over half having had a painless labour. The duration of pain was also reduced by a third in this group even though patients who had received an epidural block had tended to have longer labour and an incidence of assisted delivery of 51% compared with 6% in the remainder. Seventy-two per cent of the patients receiving an epidural had had as much pain as they had expected. A similar proportion (70%) was reported with simpler analgesic methods, suggesting that women may expect a certain amount of pain in labour and request further analgesic treatment when this is exceeded.
Although both labour dystocia and domestic violence during pregnancy are associated with adverse maternal and fetal outcome, evidence in support of a possible association between experiences of domestic violence and labour dystocia is sparse. The aim of this study was to investigate whether self-reported history of violence or experienced violence during pregnancy is associated with increased risk of labour dystocia in nulliparous women at term.
A population-based multi-centre cohort study. A self-administrated questionnaire collected at 37 weeks of gestation from nine obstetric departments in Denmark. The total cohort comprised 2652 nulliparous women, among whom 985 (37.1%) met the protocol criteria for dystocia.
Among the total cohort, 940 (35.4%) women reported experience of violence, and among these, 66 (2.5%) women reported exposure to violence during their first pregnancy. Further, 39.5% (n = 26) of those had never been exposed to violence before. Univariate logistic regression analysis showed no association between history of violence or experienced violence during pregnancy and labour dystocia at term, crude OR 0.91, 95% CI (0.77-1.08), OR 0.90, 95% CI (0.54-1.50), respectively. However, violence exposed women consuming alcoholic beverages during late pregnancy had increased odds of labour dystocia, crude OR 1.45, 95% CI (1.07-1.96).
Our findings indicate that nulliparous women who have a history of violence or experienced violence during pregnancy do not appear to have a higher risk of labour dystocia at term, according to the definition of labour dystocia in this study. Additional research on this topic would be beneficial, including further evaluation of the criteria for labour dystocia.
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.
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.
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.
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.
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.
The objective of the study was to explore community members’ understanding of and actions taken in cases of obstructed labour in south-western Uganda.
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.
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).
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.
obstructed labour; community members; understanding; actions; protecting own integrity; Uganda; Africa; maternal mortality; childbirth; delivery care; mobile phones; transport
The level of lactate in amniotic fluid may provide useful clinical information when assessing progress of a woman’s labour and if so, a rapid, reliable method to assess amniotic fluid lactate is required in order to be clinically relevant. However, measuring lactate levels in amniotic fluid, using portable, handheld lactate meters may be less accurate than reference laboratory instruments designed to measure lactate levels in aqueous solutions. Prior to conducting a large study, we assessed recruitment, consent and sampling procedures, and the accuracy of a handheld lactate meter to measure lactate in amniotic fluid. We compared amniotic fluid lactate results obtained using the hand held Lactate Pro (Arkray) to results obtained using reference laboratory methods ABX Pentra 400 (Horiba).
We recruited 35 nulliparous women during their antenatal hospital visits and tested amniotic fluid samples collected from 20 labouring women. The handheld Lactate Pro meter was found accurate from 9–20 mmol/L with a Passing & Bablok regression of y = 0.18 + 0.97x (95% CI 0.76–1.45). Amniotic fluid lactate results remained reliable in the presence of potential contaminants commonly encountered during labour; obstetric lubricant, blood and meconium.
The measurement of amniotic fluid lactate using the Lactate Pro meter was reliable compared to reference laboratory methods for measuring lactate levels in amniotic fluid. The pilot study enabled the refinement of information, recruitment, consenting and sampling procedures prior to commencing a large cohort study.
Dystocia; Lactate; Amniotic fluid; Labour; Point of care
Care for women during the third stage aims to reduce the risk of major haemorrhage, but is very variable. The current World Health Organisation (WHO) recommendation is that care should include administration of a uterotonic (oxytocin, if it is available) soon after birth of the baby, delayed cord clamping, and delivery of the placenta by controlled cord traction.
To ascertain care policies used during the third stage of labour in maternity units in Syria, we conducted a survey of 69 maternity units in obstetric and general public hospitals. A brief questionnaire was administered by face to face interview or telephone with senior obstetricians and midwives. Outcome measures were the use of prophylactic uterotonic drugs, timing of cord clamping, use of controlled cord traction, and treatment for postpartum haemorrhage. Obstetricians were asked about both vaginal and caesarean births, midwives only about vaginal births.
Responses were obtained for 66 (96%) hospitals: a midwife and an obstetrician were interviewed in 40; an obstetrician only in 20; a midwife only in 6. Responses were similar, although midwives were more likely to report that the umbilical cord was clamped after 1-3 minutes or after cessation of pulsation (2/40 obstetricians and 9/40 midwives). Responses have therefore been combined.
One hospital reported never using a prophylactic uterotonic drug. The uterotonic was Syntometrine® (oxytocin and ergometrine) in two thirds of hospitals; given after delivery of the placenta in 60 (91%) for vaginal births, and in 47 (78%) for caesarean births. Cord clamping was within 20 seconds at 42 hospitals 64%) for vaginal births and 45 (75%) for caesarean births. Controlled cord traction was never used in a quarter (17/66) of hospitals for vaginal births and a half (32/60) for caesarean births.
68% of respondents (45/66) thought there was a need for more randomised trials of interventions during the third stage of labour.
Most maternity units report using Syntometrine®, usually given after delivery of the placenta, clamping the cord within 20 seconds, and using controlled cord traction.
This study at the Logan Hospital, Australia, compared the outcome of induction of labour (IOL) in nulliparous women following replacement of Cervidil with Prostin. Eighty-two nulliparous women were identified for this retrospective cohort study over a period of three months on either side of the changed practice. Forty-four women received Prostin and 38 received Cervidil. Baseline characteristics were similar amongst the groups including maternal age, mean gestational age, and modified Bishop's score at the commencement of IOL. The incidence of amniotomy, oxytocin augmentation of labour, and rate of epidural use did not differ significantly between the groups. The mean time to delivery (vaginally or abdominally) showed a significant difference, with women receiving Prostin delivering earlier than those having Cervidil (P = 0.018). Women receiving Prostin were more likely to have assisted vaginal delivery compared to the Cervidil group (P = 0.04).
HIV screening in a labour ward is the last opportunity to initiate an antiretroviral prophylaxis among pregnant women living with HIV to prevent mother-to-child HIV transmission. Little is known about the feasibility and acceptability of HIV screening during labour in West Africa.
A cross-sectional survey was conducted in the labour ward at the Tokoin Teaching Hospital in Lomé (Togo) between May and August 2010. Pregnant women admitted for labour were randomly selected to enter the study and were interviewed on the knowledge of their HIV status. Clinical and biological data were collected from the individual maternal health chart. HIV testing or re-testing was systematically proposed to all pregnant women. Among 1530 pregnant women admitted for labour, 508 (32.2%) were included in the study. Information on HIV screening was available in the charts of 359 women (71%). Overall, 467 women accepted HIV testing in the labour ward (92%). The HIV prevalence was 8.8% (95% confidence interval: 6.4 to 11.7%). Among the 41 women diagnosed as living with HIV during labour, 34% had not been tested for HIV during pregnancy and were missed opportunities. Antiretroviral prophylaxis had been initiated antenatally for 24 women living with HIV and 17 in the labour room.
This study is the first to show in West Africa that HIV testing in a labour room is feasible and well accepted by pregnant women. HIV screening in labour rooms needs to be routinely implemented to reduce missed opportunities for intervention aimed at HIV care and prevention, especially PMTCT.
HIV; mother-to-child transmission; acceptance; labour; Africa
Objective To evaluate the reproductive outcome and the mode of delivery in subsequent pregnancies after instrumental vaginal delivery in theatre or caesarean section at full dilatation.
Design Prospective cohort study.
Setting Two urban hospitals with a combined total of 10 000 deliveries a year.
Participants A cohort of 393 women with term, singleton, cephalic pregnancies who needed operative delivery in theatre during the second stage of labour from February 1999 to February 2000. Postal questionnaires were received from 283 women (72%) at three years after the initial delivery.
Main outcome measure Mode of delivery in the subsequent pregnancy.
Results 140 women (49%) achieved a further pregnancy at three years. 91/283 (32%) women wished to avoid a further pregnancy. Women were more likely to aim for vaginal delivery (87% (47/54) v 33% (18/54); adjusted odds ratio 15.55 (95% confidence interval 5.25 to 46.04)) and more likely to have a vaginal delivery (78% (42/54) v 31% (17/54); 9.50 (3.48 to 25.97)) if they had had a previous instrumental vaginal delivery rather than a caesarean section. There was a high rate of vaginal delivery after caesarean section among women who attempted vaginal delivery 17/18 (94%). In both groups, fear of childbirth was a frequently reported reason for avoiding a further pregnancy (51% after instrumental vaginal delivery, 42% after caesarean section; 1.75 (0.58 to 5.25)).
Conclusion Instrumental vaginal delivery offers advantages over caesarean section for future delivery outcomes. The psychological impact of operative delivery requires urgent attention.
To compare the annual incidence rates of caesarean delivery between induction of labour and expectant management in the setting of macrosomia.
This is a retrospective cohort study.
Deliveries in the USA in 2003.
Singleton births of macrosomic neonates to low-risk nulliparous women at 39 weeks of gestation and beyond.
Women who had induction of labour at 39 weeks of gestation with a neonatal birthweight of 4000 ± 125 g (3875–4125 g) were compared with women who delivered (either induced or spontaneous labour) at 40, 41 or 42 weeks (i.e. expectant management), assuming an intrauterine fetal weight gain of 200 g per additional week of gestation. Similar comparisons were made at 40 and 41 weeks of gestation. Chi-square test and multivariable logistic regression analysis were used for statistical comparison.
Main outcome measures
Method of delivery, 5-minute Apgar scores, neonatal injury.
There were 132 112 women meeting the study criteria. In women whose labours were induced at 39 weeks and who delivered a neonate with a birthweight of 4000 ± 125 g, the frequency of caesarean was lower compared with women who delivered at a later gestational age (35.2% versus 40.9%; adjusted OR 1.25, 95% CI 1.17–1.33). This trend was maintained at both 40 weeks (36.1% versus 42.6%; adjusted OR 1.31, 95% CI 1.23–1.40) and 41 weeks (38.9% versus 41.8%; adjusted OR 1.16, 95% CI 1.06–1.28) of gestation.
In the setting of known birthweight, it appears that induction of labour may reduce the risk of caesarean delivery. Future research should concentrate on clinical and radiological methods to better estimate birthweight to facilitate improved clinical care. These findings deserve examination in a large, prospective, randomised trial.
Induction of labour; macrosomia; mode of delivery
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.
This study examines the possible reasons for increased obstetric activity in Denmark over the past 25 years. Since 1960 there has been a substantial increase in the average number of hospital admissions (from 10 to 32 per 100 deliveries), in deliveries diagnosed as complicated (from 15 to 49%), and above all in major interventions at delivery (from 4 to 22%). In spite of this increase in activity there is no evidence that the postwar trend of decreasing perinatal mortality has been further improved during the period of study. It seems possible that the rising level of activity is the result of increasing availability of new technology, decreasing numbers of deliveries and unchanged obstetric staffing levels, with an increased tendency to diagnose and intervene in "at risk" pregnancies. There is a need to determine how the current level of obstetric activity has arisen. Since there is evidence for an increased expectation of intervention by pregnant women, the theory of supplier induced demand may be among the leading contenders to be tested.