Epidural analgesia for low risk labour determines the rate of instrumental deliveries but not that of caesarean sections

Midwives' perception of the intrapartum risk of healthy nulliparae in spontaneous labour, in The Flanders, Belgium

OBJECTIVE

to explore midwives' perception of intrapartum risk for healthy nulliparous women in spontaneous labour at term of a healthy singleton pregnancy, in the Belgian Flanders, and to compare these results with those of a previous study undertaken in England.

DESIGN

survey of the care midwives would advocate and their perception of intrapartum risk using a standardised scenario. This study replicates part of a survey undertaken with British midwives (Mead & Kornbrot 2004b). With an added section to capture the particulars of the Belgian situation and explore the likelihood of midwives being fully responsible for the whole intrapartum care of healthy women, including their delivery. The questionnaire was translated into Dutch by MR and distributed by the Flemish Midwives' Association (Vlaamse Organisatie van Vroedvrouwen-VLOV).

PARTICIPANTS

all 845 midwives and 143 student midwives who were members of VLOV were sent a questionnaire with their invitation to take part in their annual conference. Two hundred and seventy-five midwives and 107 students attended the conference, and 128 questionnaires were returned at the conference: 99 midwives (36% of the attendees), 26 students (24% of attendees), with three unidentified respondents. This convenience sample represented 12% of all midwives and 18% of all students.

ANALYSIS

SPSS for Windows was used for the statistical analysis. Descriptive statistics were used and differences between categorical variables were analysed using chi(2) and Fisher's Exact tests, and differences between continuous variables were analysed by analysis of variance.

FINDINGS

midwives generally described a more medicalised approach to intrapartum care on admission and during the first stage of labour than their British counterparts, but were much more optimistic about the chances of healthy women in spontaneous labour achieving a normal delivery within 12 hours. However, Belgian midwives had only a limited ability to undertake normal deliveries because of the high proportion of obstetricians who fulfil this responsibility. This contravenes the European Union (EU) directive on the activities of the midwife.

KEY CONCLUSIONS

despite much greater involvement of obstetricians in the care, of women suitable for full midwifery care, and a more medicalised approach to intrapartum care, the Belgian Flanders have a significantly lower caesarean section rate than the UK. The inability of Belgian midwives to fulfil the activities of the midwives as identified by the EU directives raises questions about the migration of midwives trained in Belgium to other EU member states.

Issues of consent for regional analgesia in labour: a survey of obstetric anaesthetists

Anaesthetists are legally obliged to obtain consent and inform patients of material risks prior to administering regional analgesia in labour. We surveyed consultant members of the Australian and New Zealand College of Anaesthetists with a special interest in obstetric anaesthesia, in order to identify and compare which risks of regional analgesia they report discussing with women prior to and during labour. We also asked about obstetric anaesthetists' beliefs about informed consent, the type of consent obtained and its documentation. Of 542 questionnaires distributed, 291 responses (54%) were suitable for analysis. The five most commonly discussed risks were post dural puncture headache, block failure, permanent neurological injury, temporary leg weakness and hypotension. Obstetric anaesthetists reported discussing a mean of 8.0 (SD 3.8) and 10 (SD 3.8) risks in the labour and antenatal settings respectively. Nearly 20% of respondents did not rank post dural puncture headache among their top five most important risks for discussion. Seventy percent of respondents indicated that they believe active labour inhibits a woman's ability to give 'fully informed consent'. Over 80% of respondents obtain verbal consent and 57 (20%) have no record of the consent or its discussion. Obstetric anaesthetists reported making a considerable effort to inform patients of risks prior to the provision of regional analgesia in labour. Verbal consent may be appropriate for labouring women, using standardized forms that serve as a reminder of the risks, and a record of the discussion. Consensus is required as to what are the levels of risk from regional analgesia in labour.

An intrapartum intervention scoring system for the comparison of maternity units’ intrapartum care of nulliparous women suitable for midwifery-led care

OBJECTIVE

To develop an intrapartum intervention scoring tool which could be used to define maternity units as either 'lower intrapartum intervention' or 'higher intrapartum intervention' units. This scoring tool was designed to form the basis of a comparison of the perception of risk by midwives working in either 'lower intrapartum intervention' or 'higher intrapartum intervention' units.

DESIGN

Three aspects were included: (1) the systematic data reduction of the St. Mary's Maternity Information System database used by 11 maternity units to include Caucasian nulliparous women suitable for midwifery-led care; (2) the calculation and the ranking of frequency distributions for the following interventions/management: (a) the management of breech presentation and of one previous caesarean section, the choice of home birth; and (b) augmentation of labour, use of electronic fetal monitoring, use of epidural, method of delivery; (3) the sum of the individual intrapartum ranking marks made up the final intrapartum score for each unit.

RESULTS

Intrapartum interventions varied considerably between units. The scoring system enabled units to be described as either 'Lower intrapartum intervention' or 'Higher intrapartum intervention' units.

CONCLUSIONS

Routinely collected computerised data can be used to identify the outcomes of intrapartum care. This study suggests that the analysis of computerised data could provide a suitable basis for the audit and the comparison of intrapartum interventions for the care of women suitable for midwifery-led care.

Outcome after elective labor induction in nulliparous women: a matched cohort study

OBJECTIVE

To determine whether elective induction of labor in nulliparous women is associated with changes in fetomaternal outcome when compared with labor of spontaneous onset.

STUDY DESIGN

All 80 labor wards in Flanders (Northern Belgium) comprised a matched cohort study. From 1996 through 1997, 7683 women with elective induced labor and 7683 women with spontaneous labor were selected according to the following criteria: nulliparity, singleton pregnancy, cephalic presentation, gestational age at the time of delivery of 266 to 287 days, and birth weight between 3000 and 4000 g. Each woman with induced labor and the corresponding woman with spontaneous labor came from the same labor ward, and they had babies of the same sex. Both groups were compared with respect to the incidence of cesarean delivery or instrument delivery and the incidence of transfer to the neonatal ward.

RESULTS

Cesarean delivery (9.9% vs 6.5%), instrumental delivery (31.6% vs 29.1%), epidural analgesia (80% vs 58%), and transfer of the baby to the neonatal ward (10.7% vs 9.4%) were significantly more common (P <.01) when labor was induced electively. The difference in cesarean delivery was due to significantly more first-stage dystocia in the induced group. The difference in neonatal admission could be attributed to a higher admission rate for maternal convenience when the women had a cesarean delivery.

CONCLUSION

When compared with labor of spontaneous onset, elective labor induction in nulliparous women is associated with significantly more operative deliveries. Nulliparous women should be informed about this before they submit to elective induction.