Showing papers in "Birth-issues in Perinatal Care in 2001"

Do women get posttraumatic stress disorder as a result of childbirth? A prospective study of incidence.

Abstract: BACKGROUND: Recent research suggests that a proportion of women may develop posttraumatic stress disorder after birth. Research has not yet addressed the possibility that postpartum symptoms could be a continuation of the disorder in pregnancy. This study aimed to test the idea that some women develop posttraumatic stress disorder as a result of childbirth, and to provide an estimate of the incidence using a prospective design, which controls for the disorder in pregnancy. Method: This prospective study assessed 289 women at three time points: 36 weeks gestation and 6 weeks and 6 months postpartum. The prevalence of posttraumatic stress disorder was assessed by questionnaire at each time point, and the incidence was examined after removing women who had severe symptoms of posttraumatic stress disorder or clinical depression in pregnancy. RESULTS: After removing women at the first time point, 2.8 percent of women fulfilled criteria for the disorder at 6 weeks postpartum and this decreased to 1.5 percent at 6 months postpartum. CONCLUSIONS: The results suggest that at least 1.5 percent of women may develop chronic posttraumatic stress disorder as a result of childbirth. It is important to increase awareness about the disorder and to give health professionals access to simple screening tools. Intervention is possible at several levels, but further research is needed to guide this intervention.

Postpartum maternal oxytocin release by newborns: effects of infant hand massage and sucking.

Abstract: Background:Newborns placed skin-to-skin with their mothers show an inborn sequence of behavior similar to that seen in other mammals. The purpose of this study was to make a detailed exploration of hand movements and sucking behavior in healthy term newborns who were placed skin-to-skin on their mothers' chests, and to study maternal oxytocin release in relation to these behaviors.Methods:Ten vaginally delivered infants whose mothers had not been exposed to maternal analgesia were video-recorded from birth until the first breastfeeding. Video protocols were developed based on observations of the videotapes. Each infant's hand, finger, mouth, and tongue movements, positions of the hand and body, and sucking behavior were assessed every 30 seconds. Maternal blood samples were collected every 15 minutes, and oxytocin levels were analyzed by radioimmunoassay. A statistical test for establishing the relationship between maternal oxytocin levels and infants' hand movements or sucking behavior was developed.Results:Infants used their hands to explore and stimulate their mother's breast in preparation for the first breastfeeding. A coordinated pattern of infant hand and sucking movements was also identified. When the infants were sucking, the massagelike hand movements stopped and started again when the infants made a sucking pause. Periods of increased massagelike hand movements or sucking of the mother's breast were followed by an increase in maternal oxytocin levels (p < 0.005). Conclusions:The findings indicate that the newborns use their hands as well as their mouths to stimulate maternal oxytocin release after birth, which may have significance for uterine contraction, milk ejection, and mother-infant interaction.

Women's preference for a cesarean section: incidence and associated factors

Abstract: Background:Few studies have examined women's preferences for birth. The object of this study was to determine the incidence of women's preferred type of birth, and the reasons and factors associated with their preference.Methods:Three hundred and ten women between 36 and 40 weeks' gestation were recruited from the antenatal clinic of a major metropolitan teaching hospital and the consulting rooms of six private obstetricians in Brisbane, Australia. Participants completed a questionnaire asking about their preferred type of birth, reasons for their preference, preparation for childbirth, level of anxiety and concerns, and the influence of the primary caregiver.Results:Two hundred and ninety women (93.5%) preferred a spontaneous vaginal birth; 20 women (6.4%) preferred a cesarean section. Of the latter group, most had a current obstetric complication or experienced a previously complicated delivery (p <0.001); 1 woman (0.3%) preferred a cesarean section in the absence of any known current or previous obstetric complication. Women who preferred a cesarean section were more anxious, were generally poorly informed of the risks of this procedure, and/or overestimated the safety of the procedure.Conclusions:Women who preferred a cesarean section were more likely to have experienced this type of birth previously and to have negative feelings about it. To decrease women's preference for a cesarean section, practitioners should reduce the primary cesarean delivery rate and improve the quality of emotional care for women who require a cesarean section. Caregivers should engage in a sensitive discussion of the risks and benefits of various birth options, including a vaginal birth after cesarean, with women who have previously experienced a cesarean birth before they make decisions about mode of delivery in a subsequent pregnancy.

Maternal analgesia during labor disturbs newborn behavior: effects on breastfeeding, temperature, and crying.

Abstract: Newborns not exposed to analgesia when placed on the mothers chest exhibit an inborn pre-feeding behavior. This study was performed to assess the effects of different types of analgesia during labor on the development of spontaneous breast-feeding movements crying behavior and skin temperature during the first hours of life in healthy term newborns. Video recordings were made of 28 newborns who had been dried and placed in skin-to-skin contact between their mothers breasts immediately after delivery. The video recordings were analyzed blindly with respect to infant exposure to analgesia. Defined infant behaviors were assessed every 30 seconds. Group 1 mothers (n = 10) had received no analgesia during labor group 2 mothers (n = 6) had received mepivacaine via pudendal block and group 3 mothers (n = 12) had received pethidine or bupivacaine or more than one type of analgesia during labor. All infants made finger and hand movements but the infants massage-like hand movements were less frequent in infants whose mothers had received labor analgesia. A significantly lower proportion of group 3 infants made hand-to- mouth movements (p < 0.001) and a significantly lower proportion of the infants in groups 2 and 3 touched the nipple with their hands before suckling (p < 0.01) made licking movements (p < 0.01) and sucked the breast (p < 0.01). Nearly one-half of the infants all in groups 2 or 3 did not breastfeed within the first 2.5 hour of life. The infants whose mothers had received analgesia during labor had higher temperatures (p = 0.03) and they cried more (p = 0.05) than infants whose mothers had not received any analgesia. The present data indicate that several types of analgesia given to the mother during labor may interfere with the newborns spontaneous breast-seeking and breast-feeding behaviors and increase the newborns temperature and crying. (authors)

WHO principles of perinatal care: the essential antenatal, perinatal, and postpartum care course.

Abstract: World Health Organization (WHO) recommendations and meta-analyses of controlled trials have concluded that inappropriate perinatal care and technology continue to be practiced widely throughout the world, despite the acceptance of evidence-based principles and care. The WHO Regional Office for Europe, in consultation with policy makers and reproductive health experts recently proposed ten "Principles of Perinatal Care," which have been endorsed by the reproductive health units of most member states. A comprehensive training program, based on the principles, is now being offered throughout the European region. This paper describes the development of the WHO principles and the WHO training course "Essential Antenatal, Perinatal and Postpartum Care." Together they provide an innovative model of evidence-based and psychosocially sensitive care for the future guidance of perinatal policy makers and caregivers worldwide.

Maternity care practices: implications for breastfeeding.

Abstract: Background:Many United States mothers never breastfeed their infants or do so for very short periods. The Baby-Friendly Hospital Initiative was developed to help make breastfeeding the norm in birthing environments, and consists of specific recommendations for maternity care practices. The objective of the current study was to assess the impact of the type and number of Baby-Friendly practices experienced on breastfeeding.Methods:A longitudinal mail survey (1993–1994) was administered to women prenatally through 12 months postpartum. The study focused on the 1085 women with prenatal intentions to breastfeed for more than 2 months who initiated breastfeeding, using data from the prenatal and neonatal periods. Predictor variables included indicators of the absence of specific Baby-Friendly practices (late breastfeeding initiation, introduction of supplements, no rooming-in, not breastfeeding on demand, use of pacifiers), and number of Baby-Friendly practices experienced. The main outcome measure was breastfeeding termination before 6 weeks.Results:Only 7 percent of mothers experienced all five Baby-Friendly practices. The strongest risk factors for early breastfeeding termination were late breastfeeding initiation and supplementing the infant. Compared with mothers experiencing all five Baby-Friendly practices, mothers experiencing none were approximately eight times more likely to stop breastfeeding early. Additional practices decreased the risk for early termination.Conclusion:Increased Baby-Friendly Hospital Initiative practices improve the chances of breastfeeding beyond 6 weeks. The need to work with hospitals to increase adoption of these practices is illustrated by the small proportion of mothers who experienced all five practices measured in this study.

Intravenous Oxytocin Alone for Cervical Ripening and Induction of Labour

Abstract: A substantive amendment to this systematic review was last made on 25 May 2001. Cochrane reviews are regularly checked and updated if necessary. ABSTRACT Background: Oxytocin is the commonest induction agent used worldwide. It has been used alone, in combination with amniotomy or following cervical ripening with other pharmacological or non-pharmacological methods. Prior to the introduction of prostaglandin agents oxytocin was used as a cervical ripening agent as well. In developed countries oxytocin alone is more commonly used in the presence of ruptured membranes whether spontaneous or artificial. In developing countries where the incidence of HIV is high, delaying amniotomy in labour reduces vertical transmission rates and hence the use of oxytocin with intact membranes warrants further investigation. This review will address the use of oxytocin alone for induction of labour. Amniotomy alone or oxytocin with amniotomy for induction of labour has been reviewed elsewhere in the Cochrane Library. Trials which consider concomitant administration of oxytocin and amniotomy will not be considered. This is one of a series of reviews of methods of cervical ripening and labour induction using a standardised methodology. Objectives: To determine the effects of oxytocin alone for third trimester cervical ripening or induction of labour in comparison with other methods of induction of labour or placebo/no treatment. Search strategy: The Cochrane Pregnancy and Childbirth Group Trials Register, the Cochrane Controlled Trials Register and bibliographies of relevant papers. Last searched: May 2001. Selection criteria: The criteria for inclusion included the following: (1) clinical trials comparing vaginal prostaglandins used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or control group; (3) adequate allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions. Data collection and analysis: A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. The initial data extraction was done centrally, and incorporated into a series of primary reviews arranged by methods of induction of labour, following a standardised methodology. The data are to be extracted from the primary reviews into a series of secondary reviews, arranged by category of woman. Main results: In total, 110 trials were considered; 52 have been excluded and 58 included examining a total of 11,129 women. Comparing oxytocin alone with expectant management: Oxytocin alone reduced the rate of unsuccessful vaginal delivery within 24 hours when compared with expectant management (8.3% versus 54%, relative risk (RR) 0.16, 95% confidence interval (CI) 0.10,0.25) but the caesarean section rate was increased (10.4% versus 8.9%, RR 1.17, 95% CI 1.01,1.36). This increase in caesarean section rate was not apparent in the subgroup analyses. Women were less likely to be unsatisfied with induction rather than expectant management, in the one trial reporting this outcome (5.5% versus 13.7%, RR 0.43, 95% CI 0.33, 0.56). Comparing oxytocin alone with vaginal prostaglandins: Oxytocin alone was associated with an increase in unsuccessful vaginal delivery within 24 hours (52% versus 28%, RR 1.85, 95% CI 1.41, 2.43), irrespective of membrane status, but there was no difference in caesarean section rates (11.4% versus 10%, RR 1.12, 95% CI 0.95, 1.33). Comparing oxytocin alone with intracervical prostaglandins: Oxytocin alone was associated with an increase in unsuccessful vaginal delivery within 24 hours when compared with intracervical PGE2 (51% versus 35%, RR 1.49, 95% CI 1.12,1.99). For all women with an unfavourable cervix regardless of membrane status, the caesarean section rates were increased (19.0% versus 13.1%, RR 1.42, 95% CI 1.11, 1.82). Reviewers' conclusions: Overall, comparison of oxytocin alone with either intravaginal or intracervical PGE2 reveals that the prostaglandin agents probably overall have more benefits than oxytocin alone. The amount of information relating to specific clinical subgroups is limited, especially with respect to women with intact membranes. Comparison of oxytocin alone to vaginal PGE2 in women with ruptured membranes reveals that both interventions are probably equally efficacious with each having some advantages and disadvantages over the others. With respect to current practice in women with ruptured membranes induction can be recommended by either method, and in women with intact membranes there is insufficient information to make firm recommendations. Citation: Kelly AJ, Tan B. Intravenous oxytocin alone for cervical ripening and induction of labour (Cochrane Review). In: The Cochrane Library, 3, 2001. Oxford: Update Software.

Perinatal Depression: A Randomized Controlled Trial of an Antenatal Education Intervention for Primiparas

Abstract: BACKGROUND: Depression can be an unexpected and distressing companion for a woman during the major life transition of becoming a mother for the first time. Researchers now demonstrate that approximately 50 percent of women will experience perinatal distress. Therefore, the etiology and management of perinatal depression is essential for a quality care of childbearing women. The objectives of this study were to develop an education intervention tailored to the information needs of primiparous women about perinatal depression, to deliver this intervention antenatally, and to conduct a randomized controlled trial to determine the effect of the antenatal education intervention in the reduction of postnatal depression. METHOD: A prospective, randomized controlled trial of the education intervention (n = 206) was conducted at three sites in Australia. The outcome of changes in mood state was measured by the Profile of Mood States questionnaire once antenatally (12-28 wk), and twice postnatally (8-12 and 16-24 wk); social support and demographic data were also collected. The education package was administered to the intervention group at the antenatal assessment of mood. RESULTS: A significant and steady reduction in scores (overall and on the subscales) was observed over time for both groups that showed significant improvement in symptoms of depression. No difference was detected when comparing the intervention group with the control group. Additional multivariate regression analyses revealed no relevant influence of social support or demographic variables. CONCLUSIONS: Women in both the study and control groups were more depressed antenatally than postnatally. The finding that the education intervention made no difference challenges the two strongly held tenets of health education in childbearing women-that depression can be reduced through education and that antenatal education interventions can endure into the postnatal period.

A waste of life: fathers' experience of losing a child before birth.

Abstract: Background The prenatal loss of an expected child entails parental despair and grief. The grief after a stillborn child is sometimes described as a "forgotten form of grief" and the fathers as the "forgotten mourners." Our aim was to describe how fathers experienced losing a child as a result of intrauterine death. Method Eleven men were interviewed 5 to 27 months after the intrauterine death of their child during weeks 32 to 42 of pregnancy. The interviews were analyzed using a phenomenological methodology. Results After being informed of the infant's death, most fathers first wanted their partners to have a cesarean section, but all later thought that it would be right for the child to be delivered vaginally. A strong feeling of frustration and helplessness came over them during and after the delivery. Several men found meaning and relief in their grief by supporting their partner. Tokens of remembrance from the child were invaluable, and fathers appreciated that the staff collected these items, even if the parents declined them. The perceived prerequisite for resuming their everyday lives consisted of the support they received from the hospital staff and precious memories of the child. The most important comfort in their grief was a good relationship with their partner. Some fathers missed having a man to talk to both at the time of the stillbirth and subsequently. Conclusion The fathers' general trust in life and the natural order was suddenly and unexpectedly severely tested by the death of their child, which they perceived as a terrible waste of life. They sought understanding as grieving men and fathers from both the hospital personnel and their partners, as well as from relatives. Being able to protect their partner and to grieve in their own way was important to the fathers.

Postpartum Positioning and Attachment Education for Increasing Breastfeeding: A Randomized Trial

Abstract: Although lactation experts suggest that a correct positioning and attachment technique reduces breast-feeding problems and enhances long-term breast-feeding evidence from randomized trials is lacking. The objective of this study was to evaluate the effect of postpartum positioning and attachment education on breast-feeding outcomes in first-time mothers. A randomized trial was performed in a public hospital in Adelaide South Australia where 160 first-time mothers were randomly allocated to receive either structured one-to-one education (experimental group) or usual postpartum care (control group) within 24 hours of birth. The primary outcome was breast-feeding at 6 weeks and 3 and 6 months postpartum; other outcomes were nipple pain and trauma in hospital and at 6 weeks and 3 and 6 months and satisfaction with breast-feeding. No significant differences occurred in breastfeeding rates between the groups at each endpoint although a trend in the direction of lower rates was seen at each endpoint in the experimental group. This group reported less nipple pain on days 2 (p = 0.004) and 3 (p = 0.04) but this was not sustained on follow-up. No differences were observed in nipple trauma in hospital or in self-reported nipple pain and/or trauma at the three endpoints. Experimental group women were less satisfied with breast-feeding at 3 and 6 months postpartum when using a one-item measure; however a multiple-item measure showed no significant differences at the three endpoints. The intervention did not increase breast- feeding duration at any assessment time or demonstrate any differences between the groups on secondary outcomes. The trend toward lower breast-feeding rates in the experimental group suggests a need for a larger trial to evaluate whether or not postpartum positioning and attachment education may negatively affect breastfeeding. (authors)

Assessing women's preferences for intrapartum care.

Abstract: Background: Recent government reports have recommended involving consumers in the planning of health services. Although satisfaction surveys have traditionally been used, they have several limitations. This paper describes a relatively new method of eliciting consumer preferences that allows respondents (women) to indicate the importance that they attribute to specific aspects of a service. The aim was to explore the feasibility of using a discrete choice experiment to assess the importance to women of different aspects of intrapartum care. Methods: In this pilot study of 301 women at low obstetric risk, data were collected using an anonymous self-complete questionnaire given to each participant by the midwife at the booking visit. Results: The results of the regression model suggest that respondents prefer maternity units that offer greater continuity of caregiver, more methods of pain relief, continuous fetal heart rate monitoring, a homely appearance, routine involvement of medical staff, and greater involvement for the woman in the decision-making process. Although all attributes were important to women, they were not all of equal importance. For example, if continuity of caregiver were achieved at the expense of decreasing the availability of pain relief then women would be worse off. Conclusions: The discrete choice experiment appears to be a useful tool in assessing the strength of women's preferences for different aspects of maternity care. Future research should include a qualitative approach to explore in greater depth the processes involved in shaping women's preferences.

Immersion in water in the first stage of labor: a randomized controlled trial.

Abstract: Background:Current forms of analgesia often have significant side effects for women in labor. Bathing in warm water during labor has been reported to increase a woman's comfort level and cause a reduction in painful contractions. The objective of this trial was to compare immersion in warm water during labor with traditional pain management for a range of clinical and psychological outcomes.Methods:A prospective randomized controlled trial of 274 pregnant women, who were free from medical and obstetric complications and expecting a singleton pregnancy at term, was conducted at the Women's and Children's Hospital, a maternity tertiary referral center in Adelaide, South Australia. Women in labor were randomized to an experimental group who received immersion in a bath or to a nonbath group who received routine care. Pharmacological pain relief was the primary outcome that was measured, and secondary outcomes included maternal and neonatal clinical outcomes, factors relating to maternal and neonatal infectious morbidity, psychological outcomes, and satisfaction with care.Results:The use of pharmacological analgesia was similar for both the experimental and control groups; 85 and 77 percent, respectively, used major analgesia. No statistical differences were observed in the proportion of women requiring induction and augmentation of labor or in rates of perineal trauma, length of labor, mode of delivery, or frequency of cardiotocographic trace abnormalities. Neonatal outcomes (birthweight, Apgar score, nursery care, meconium-stained liquor, cord pH estimations) revealed no statistically significant differences. Infants of bath group women required significantly more resuscitation than routine group women. Routine group women rated their overall experience of childbirth more positively than bath group women. Psychological outcomes, such as satisfaction with care or postnatal distress, were the same for both groups.Conclusion:Bathing in labor confers no clear benefits for the laboring woman but may contribute to adverse effects in the neonate.

Pregnant Women's Perceptions of Their Nurse's Role During Labor and Delivery

Abstract: Background Little has been studied about pregnant women's perceptions of their nurse's role during labor and delivery. The objective of this study was to determine nulliparous pregnant women's expectations of their nurse's role during labor and delivery as expressed during the last trimester of pregnancy. Method Nulliparous women in childbirth classes were asked on a questionnaire, "What do you think your nurse's role will be during labor and delivery? You may list as many things as you wish." Results Fifty-seven completed surveys were collected. The women listed a total of 174 items. Approximately 29 percent of the nursing tasks listed by the nulliparous women were related to providing them with physical comfort and emotional support, 24 percent related to providing informational support, almost 21 percent were related to providing technical nursing care, and 21 percent related to monitoring of the baby, mother, or labor progress; approximately 5 percent related to indirect care (outside the room). Conclusion The expectations of women in our study were in contrast with findings from two previous work sampling studies, in which nurses provided much less time giving women physical comfort, emotional support, and informational support than would have been expected by women in our study. Fulfilling women's expectations about childbirth can increase women's satisfaction with their birth experiences. Further studies can help maternity caregivers learn more about women's expectations.

Maternal satisfaction with active management of labor: a randomized controlled trial.

Abstract: Background Active management of labor reduces the length of labor and rate of prolonged labor, but its effect on satisfaction with care, within a randomized controlled trial, has not previously been reported. The study objectives were to establish if a policy of active management of labor affected any aspect of maternal satisfaction, and to determine the independent explanatory variables for satisfaction with labor care in a low-risk nulliparous obstetric population. Methods Nulliparous women at National Women's Hospital in Auckland, New Zealand, in spontaneous labor at term with singleton pregnancy, cephalic presentation, and without fetal distress were randomized after the onset of labor to active management (n = 320) or routine care (n = 331). Active management included early amniotomy, two-hourly vaginal assessments, and early use of high dose oxytocin for slow progress in labor. Routine care was not prespecified. Maternal satisfaction with labor care was assessed by postal questionnaire at 6 weeks postpartum. Sensitivity analyses were performed, and logistic regression models were developed to determine independent explanatory variables for satisfaction. Results Of the 651 women randomized in the trial, 482 (74%) returned the questionnaires. Satisfaction with labor care was high (77%) and did not significantly differ by treatment group. This finding was stable when sensitivity analysis was performed. The first logistic regression model found independent associations between satisfaction and adequate pain relief, one-to-one midwifery care, adequate information and explanations by staff, accurate expectation of length of labor, not having a postpartum hemorrhage, and fewer than three vaginal examinations during labor. The second model found fewer than three vaginal examinations and one-to-one midwifery care as significant explanatory variables for satisfaction with labor care. Conclusions Active management did not adversely affect women's satisfaction with labor and delivery care in this trial. Future studies should concentrate on measurement of potential predictors before and during labor.

Position for newborn sleep: associations with parents' perceptions of their nursery experience.

Abstract: Background In the United States, sudden infant death syndrome is the leading cause of death among infants between the ages of 1 and 12 months. Although its etiology is unclear, infants who sleep in the prone or side positions are at increased risk. The objective of this study was to examine the association between the perceptions of inner city parents about teaching and modeling during the postpartum period of infant sleeping position, and their choice of sleeping position for their infants. Methods A convenience sample of parents of 100 healthy infants who came for the 2-week well-child visit at an urban primary care center were invited to complete a questionnaire and to report on the position in which infants were placed for sleep. Results Forty-two percent of parents reported that they usually placed their infants in the supine position for sleep; 26 percent placed their infants to sleep in the prone position at least some of the time. Parents who reported being told by a doctor or a nurse to have their infants sleep in the supine position were more likely to choose that position. Similarly, those who reported seeing their infants placed to sleep exclusively in the supine position in the hospital were also more likely usually to choose that position. Parents who reported that they both were told by a doctor or a nurse to put their infants to sleep in the supine position and reported seeing their infants exclusively placed that way in the nursery were the most likely usually to choose that position for their infants to sleep. Conclusions Perceptions by parents of instructions from a doctor or a nurse of the position in which the infants were placed in the nursery were associated with the position parents reported placing their infants to sleep at home. Efforts to promote the supine sleeping position in the inner-city setting should address both practices and education provided to parents in the nursery during the postpartum hospital stay and should be sufficiently powerful to align their perceptions of the postpartum experience with current American Academy of Pediatrics recommendations.

Rates of cesarean births in Hong Kong: 1987-1999.

Abstract: High cesarean birth rates are an issue of international public health concern. The purpose of this paper was to examine the annual incidence and secular trend of cesarean births in Hong Kong and to correlate these rates with socioeconomic demographic and health indicators for the population since 1987. This was a descriptive and ecologic study Annual population rates of cesarean sections were estimated for 1987 from a population-based survey and for 1993 through 1999 from government data sources. The number of excess cesarean sections was calculated for each year using the 15 percent upper limit as proposed by the World Health Organization. From 1987 to 1999 the overall annual cesarean section rate rose steadily from 16.6 to 27.4 per 100 hospital deliveries resulting in a 65 percent increase over 12 years. The mean difference in rates of surgical delivery between public (mean public = 16.0%) and private (mean private = 43.4%) institutions was 27.4 percent (95% confidence interval (CI) = 24.1 30.7; p < 0.001). This is the first systematic report of secular variations of cesarean delivery rates in Asia. The high rates and increasing trend represent an unnecessary excess risk for mothers and their infants. Various strategies combating high cesarean rates have been proposed and have succeeded elsewhere. Concerted action from health care professionals public health authorities the general population and the media is urgently required to implement solutions to reduce the rate of cesarean delivery. (authors)

Implementing change: becoming baby-friendly in an inner city hospital.

Abstract: The Baby-Friendly Hospital Initiative of the United Nations Children's Fund and the World Health Organization dramatically raises breastfeeding rates when implemented. To date, only 27 of the 16,000 Baby-Friendly hospitals worldwide are located in the United States. Barriers to becoming Baby-Friendly in the United States include the strength of the infant formula industry, suboptimal clinician knowledge, and the need to implement significant change throughout an institution. This paper describes how Boston Medical Center, an inner-city teaching hospital in Boston with approximately 1800 births per year, overcame numerous obstacles and, in December 1999, became the first Baby-Friendly hospital in Massachusetts.

Trends in the use of episiotomy in the United States: 1980-1998.

Abstract: Background: Despite a relative paucity of clinical evidence justifying its routine use, approximately 40 percent of all vaginal deliveries include an episiotomy. The purpose of this study is to examine trends in episiotomy in the United States from 1980 through 1998, a period during which calls increased to abandon routine episiotomy. Methods: Data were obtained from the National Hospital Discharge Survey, which is conducted annually and based on a nationally representative sample of discharges from short-stay non-Federal hospitals. Results: From 1980 through 1998 the episiotomy rate in the United States dropped by 39 percent. Rates decreased for all age and racial groups investigated, in all four geographic regions, and for all sources of payment. Significant differences remained between groups in 1998, including a higher rate for white women than for black women, and a higher rate for women with private insurance than for women with Medicaid or in the self-pay category. The incidence of first- and second-degree lacerations to the perineum increased for women without episiotomies, but the more severe third- and fourth-degree lacerations remained more frequent for women with episiotomies. Women with episiotomies were more likely to have forceps-assisted deliveries or vacuum extractions. Conclusions: Despite dramatic declines in the use of episiotomy during the last two decades, it remains one of the most frequent surgical procedures performed on women in the United States, and it continues to be performed at a higher rate for certain groups of women.

Assessing effective care in normal labor: the Bologna score.

Abstract: The intention of the "Bologna score" is to quantify, both in an individual labor and in a wider population, the extent to which labors have been managed as if they are normal as opposed to complicated. In this way it may be possible to assess both attitudes and practices within a maternity service toward the effective care of normal labor. A scoring system for normal labor was proposed at the World Health Organization (Regional Office for Europe) Task Force Meeting on Monitoring and Evaluation of Perinatal Care, held in Bologna in January 2000. This paper describes conceptual development of the scale. Recommendations for future evaluation of the Bologna score's validity and potential include field testing globally, comparison with the Apgar score, and evaluation of the relative weight contributed by each of the five measures comprising the Bologna score.

Amniotomy for Shortening Spontaneous Labour

Abstract: A substantive amendment to this systematic review was last made on 25 June 1999. Cochrane reviews are regularly checked and updated if necessary. ABSTRACT Background: Early amniotomy has been advocated as a component of the active management of labour. Several randomised trials comparing routine amniotomy to an attempt to conserve the membranes have been published. Their limited sample sizes limit their ability to address the effects of amniotomy on indicators of maternal and neonatal morbidity. Objectives: To study the effects of amniotomy on the rate of Cesarean delivery and on other indicators of maternal and neonatal morbidity (Apgar less than 7 at 5 minutes, admission to NICU). Search strategy: The register of clinical trials maintained and updated by the Cochrane Pregnancy and Childbirth Group. Selection criteria: All acceptably controlled trials of amniotomy during first stage of labour were eligible. Data collection and analysis: Data were extracted by two trained reviewers from published reports. Trials were assigned methodological quality scores based on a standardised rating system. Typical odds ratios (ORs) were calculated using Peto's method. Main results: Amniotomy was associated with a reduction in labour duration of between 60 and 120 minutes. There was a marked trend toward an increase in the risk of Cesarean delivery: OR = 1.26; 95% Confidence Interval (CI) = 0.96–1.66. The likelihood of a 5-minute Apgar score less than 7 was reduced in association with early amniotomy (OR = 0.54; 95% CI = 0.30–0.96). Groups were similar with respect to other indicators of neonatal status (arterial cord pH, NICU admissions). There was a statistically significant association of amniotomy with a decrease in the use of oxytocin: OR = 0.79; 95% CI = 0.67–0.92. Reviewers' conclusions: Routine early amniotomy is associated with both benefits and risks. Benefits include a reduction in labour duration and a possible reduction in abnormal 5-minute Apgar scores. The meta-analysis provides no support for the hypothesis that routine early amniotomy reduces the risk of Cesarean delivery. Indeed there is a trend toward an increase in Cesarean section. An association between early amniotomy and Cesarean delivery for fetal distress is noted in one large trial. This suggests that amniotomy should be reserved for women with abnormal labour progress. Citation: Fraser WD, Turcot L, Krauss I, Brisson-Carrol G. Amniotomy for shortening spontaneous labour (Cochrane Review). In: The Cochrane Library, 1, 2001. Oxford: Update Software. MeSH: Amnion/*surgery; Cesarean Section; Female; Human; *Labor; Labor Complications/*prevention & control; Pregnancy The preceding reports are abstracts of regularly updated, systematic reviews prepared and maintained by the Cochrane Collaboration. The full text of the reviews are available in The Cochrane Library (ISSN 1464-780X). The Cochrane Library is prepared and published by Update Software Ltd. All rights reserved. See www.update-software.com or contact Update Software, info@update.co.uk, for information on subscribing to The Cochrane Library in your area. Update Software Ltd, Summertown Pavilion, Middle Way, Oxford OX2 7LG, United Kingdom. (Tel: +44 1865 513902; Fax: +44 1865 516918).

Attitudes and Beliefs About Childbirth Among College Students: Results of an Educational Intervention

Abstract: Background: Research on knowledge of childbirth has focused primarily on expectant mothers. The purpose of this study was to investigate college student beliefs, knowledge of, and interest in learning more about childbirth. Methods: Qualitative research methods were used to analyze college students' written responses to a childbirth video as the first stage in a research project aimed at understanding nulliparous and prepaternity knowledge of childbirth among adolescents and young adults. Participants were 65 students at a liberal arts college in upstate New York. Results: The findings demonstrated a range of levels of awareness, interest, and knowledge. In their responses, students described childbirth as a miraculous event associated with fear of pain; students primarily knew that childbirth takes place in the hospital, where “safe and effective” pain medication is administered; students liked seeing the experiential aspect of birth; and students wanted to know about the risks and benefits of various hospital procedures, and the “spiritual” emotional aspects of giving birth. Conclusion: The findings contribute insights into how college students think about pain in childbirth, suggesting that their fear is associated with a lack of knowledge. Teaching high school students specifics about pregnancy and childbirth practices and procedures holds promise for reducing anxiety, increasing maternal control, and supporting positive birth experiences.

Reducing postnatal pain from perineal tears by using lignocaine gel: A double-blind randomized trial

Abstract: BACKGROUND: Perineal pain is one of the most common causes of maternal morbidity in the early puerperium. Several randomized trials have shown that topical application of local anesthetics is effective in reducing postepisiotomy pain, but no randomized study has assessed the efficacy of local anesthetics for other perineal trauma. This study investigated if topically applied 2 percent lignocaine gel was an effective treatment for this group of women. METHODS: A double-blind placebo controlled trial was conducted in a regional teaching hospital in the northwest of England. One hundred and forty-nine women who had sustained a first- or second-degree tear were allocated by sealed envelopes to the lignocaine gel or placebo group. The primary outcome was self-reported pain at 24 hours postdelivery as measured on a numerical rating scale (pain score). Secondary outcomes included pain scores at 48 hours, the need for oral analgesia, and maternal satisfaction. Based on a pilot study, we calculated that 128 women were required to detect a 25 percent difference in pain scores between the two groups with 80 percent power (alpha = 0.05). The pain scores of women in each trial arm were compared using the unpaired t test and 95 percent confidence intervals. RESULTS: Women using lignocaine gel had lower average pain scores, although this only reached statistical significance at 48 hours after delivery (p = 0.023). In general, women liked using the study gel. No difference was found in consumption of oral analgesia. CONCLUSIONS: This study suggested that lignocaine gel may be effective on the second postnatal day. Further research is required to assess the optimum timing of this intervention and the population that would most benefit from its use.

Single Room Maternity Care: The Nursing Response

Abstract: Background The introduction of single room maternity care in the 1990s necessitated a new approach to nursing education and practice. A focus on perinatal nursing requires competence across the spectrum of labor, delivery, postpartum and newborn care. We sought to evaluate the nursing response to this change by comparing satisfaction with the workplace environment among single room maternity care nurses before and after they worked in the setting and among nurses working in traditional birth settings. Methods Six months before the opening of a pilot seven-bed single room maternity care unit, nurses who planned to work in the new unit completed a survey about their satisfaction with aspects of their work environment. Three months after the new unit opened the survey was repeated with this study group and also by a sample of nurses working in the delivery and postpartum areas. Results Responses indicated that single room maternity care nurses before and after working in the unit were significantly more satisfied with the physical setting, their ability to respond to patients' needs, their opportunity for teaching families, the nursing practice environment, peer support, and their perceived level of competency. They rated their satisfaction significantly higher than that of their colleagues in the traditional delivery and postpartum settings. Conclusions The positive transition to single room maternity care by obstetrical nurses was demonstrated by their improved overall satisfaction with the work environment. Evaluation of the nurses' responses to changes in health care delivery has important implications for justifying new clinical approaches and planning for future changes.

Women's Perceptions of Helpful and Unhelpful Nursing Behaviors During Labor: A Study in Taiwan

Abstract: Background: The job of the nurse in labor and delivery is not only to ensure a safe delivery but also to create a positive and satisfying childbirth experience. Few studies have been conducted of women's perceptions about the ideal image of the obstetric nurse during labor, and most previous studies involved only North American or European women. The purpose of this study was to assess Taiwanese women's perspectives about their encounters with obstetric nurses during labor. Methods: Interviews of a convenience sample of 50 mothers experiencing normal childbirth in Taiwan were conducted. The interviews were tape recorded and transcribed, and the transcriptions were analyzed to develop coding categories and identify themes. Results: Sixty percent of the participants reported having received helpful nursing behaviors only; 38 percent reported having received both helpful and unhelpful nursing behaviors. Helpful labor-coping measures that were valued by participants included performing roles of emotional support providers, comforters, information/advice providers, professional technical skills providers, and advocates. Forty percent of the participants reported that some nurses had hindered their labor-coping ability by failing to provide emotional support, comfort measures, adequate or correct information/advice, or to perform technical duties. Conclusions: The ideal nursing image encompasses the roles of emotional supporter, comforter, information/advice provider, professional/technical skill provider, and advocate. The findings may help obstetric team members better understand patients' needs, and enable them to provide better support during labor and to prevent unhelpful nursing behaviors.

Does bathing newborns remove potentially harmful pathogens from the skin

Abstract: Background: Newborn infants are routinely bathed after birth partly to reduce the possibility of transmitting potential pathogens to others. The extent to which a mild soap reduces the quantity and type of microbes found on the skin through normal colonization has not been reported. The objective of the study was to compare colonization rates between infants bathed in soap and water and infants bathed in plain water. Method: One hundred and forty infants were randomly assigned to one group bathed in a mild pH neutral soap and water or to another group bathed in water alone. Microbiology swabs were taken on three occasions (before the first bath, 1 hour after the bath, and 24 hours after birth) from two sites (anterior fontanelle and umbilical area). Results: No difference occurred between groups on type or quantity of organisms found at each time period. Skin colonization is a function of time, and the quantity of organisms identified increased over time (Friedman A 2= 111.379, df = 5, p < 0.001). Conclusions: Bathing with mild soap as opposed to bathing in water alone has minimal effect on skin bacterial colonization. Skin colonization increased over time. The findings did not support the efficacy of bathing with soap and water to reduce skin colonization of bacterial pathogens. Although the incidence of potential pathogens colonizing the skin during the first day of life is low and unlikely to pose a risk to healthy newborns, health care professionals may wish to wear gloves until the infant has been bathed.

Postdischarge surveillance after cesarean section

Abstract: Background:Cesarean section is a major surgical procedure with a relatively short hospital stay. A significant rate of surgical site infection after this procedure is missed by standard inpatient surveillance. This study aimed to evaluate a method of postdischarge surveillance and compare results with the incidence of infection before discharge.Method: A postdischarge survey was sent on day 30 to 277 women who had delivered by cesarean section during the 12-month study period. A follow-up telephone interview was conducted if the questionnaire had not been returned within 2 weeks, if a diagnosis of infection could not be clearly determined from the participant's responses, or to confirm the diagnosis of infection. If follow-up was not completed, a chart audit was undertaken.Results: A total response rate of 89 percent (247/277) was obtained, and 28 women with a surgical site infection were identified from the survey. Telephone follow-up and chart review of patients with possible infection and of nonresponders identified 32 percent more postdischarge infections (14/42). The overall infection rate was 17 percent compared with 2.8 percent at discharge.Conclusions: Postdischarge surveillance is necessary to determine accurate surgical site infection rates after cesarean section, increase awareness of caregivers about infection control problems, and indicate the need for appropriate follow-up care. Women undergoing a cesarean delivery should be informed of the risk of postdischarge infection and educated about the signs and symptoms of infection.

Epidural analgesia use as a marker for physician approach to birth: implications for maternal and newborn outcomes.

Abstract: ABSRACT: Background: Understanding the association between caregiver belief systems and practice patterns is an emerging area of research. We hypothesized an association between a maternity caregiver’s belief system and his or her behavior. The study objective was to determine if a family physician’s overall approach to maternity care, as measured by average use of epidural analgesia, was associated with maternal and fetal outcomes. Methods: Retrospective analysis was conducted of the births of three cohorts of 1992 nulliparous, low-risk women attended by 96 family physicians within an 18-month period in the department of family practice at the largest maternity hospital in Canada. Cohorts were based on the physicians’ mean use of epidural analgesia for the women. Family physicians attending fewer than 5 births were excluded. The main outcome measures, by physician epidural utilization cohort, were maternal/newborn morbidity, procedure rates, consultation rates, and length of stay. Results: Family physicians were separated into cohorts based on their mean use of epidural analgesia at rates of: low, 0–30 percent (15 physicians, 263 births); medium, 31–50 percent (55 physicians, 1323 births); and high, 51–100 percent (26 physicians, 406 births). After adjustment for maternal age and race, patients of low versus high epidural users were admitted at a later state of cervical dilation (mean 4.0 vs 3.1 cm), received less electronic fetal monitoring (76.4 vs 87.2%) and oxytocin augmentation (12.2 vs 29.8%), sustained fewer malpositions (occiput posterior or transverse)(23.2 vs 34.2%), had fewer cesarean sections (14.0 vs 24.4%), less obstetric consultation (47.9 vs 63.8%), and fewer newborn special care admissions (7.2 vs 12.8%). Conclusions: In our setting, high use of epidural analgesia is a marker for a style of practice characterized by malpositions leading to dysfunctional labors and higher intervention rates leading, in turn, to excess maternal/newborn morbidity. (BIRTH 28:4 December 2001)

Eating and drinking in labor: the influence of caregiver advice on women's behavior.

Abstract: BACKGROUND Although there is much debate about eating and drinking during labor, little scientific data about its influence on the course of labor exist. In The Netherlands, most midwives and obstetricians allow women to eat and drink during normal labor. The objective of this study was to examine whether or not women were actively advised to eat and drink and if this advice affected eating and drinking behavior. METHODS A randomly selected group of midwives and obstetricians from across The Netherlands identified 211 consecutive nulliparous women to participate in the study. In a questionnaire with open-ended questions, women were asked after their delivery whether or not they were advised about eating and drinking during labor, and if so, about the nature of this advice and what they had consumed. Data were analyzed at the Leyenburg Hospital in The Hague. RESULTS Sixty-six percent of the women were not given advice about eating and drinking during labor. Women who were given advice usually followed it. In the total group, 37 percent of the women had intake other than water and of these, 75 percent ate solid food. After adjusting for other prognostic factors, the incidence of an instrumental delivery due to a nonprogressing second stage was lower in women with caloric intake (13% vs 24%, p = 0.04). CONCLUSION The study design did not enable us to draw conclusions about the cause and effect between caloric intake and labor progress. Scientific data with respect to the giving of evidence-based advice about eating and drinking during labor are lacking. Should such advice become available, women are likely to follow it.