No Pain Labor & Delivery: A Global Health Initiative's Impact on Clinical Outcomes in China

The importance of simulation-based multi professional training in obstetric anesthesia: an update

PURPOSE OF REVIEW

Simulation-based training remains an integral component of medical education by providing a well tolerated, controlled, and replicable environment for healthcare professionals to enhance their skills and improve patient outcomes. Simulation technology applied to obstetric anesthesiology continues to evolve as a valuable tool for the training and assessment of the multidisciplinary obstetric care team.

RECENT FINDINGS

Simulation-based technology has continued to play a role in training and assessment, including recent work on interdisciplinary communication, recognition, and management of obstetric hemorrhage, and support in the low or strained resource setting. The COVID-19 pandemic has accelerated the evolution of simulation-based training away from a reliance on in-situ or high-fidelity manikin-based approaches toward an increasing utilization of modalities that allow for remote or asynchronous training.

SUMMARY

The evolution of simulation for interdisciplinary training and assessment in obstetric anesthesia has accelerated, playing a greater role in aspects of communication, management of hemorrhage and supporting low or strained resource settings. Augmented reality, virtual reality and mixed reality have advanced dramatically, spurred on by the need for remote and asynchronous simulation-based training during the pandemic.

What matters to migrant women during labor and birth: Chinese mothers' experiences in Switzerland

BACKGROUND

In Switzerland, foreigners account for 25.3% of the permanent resident population, and the fertility rate of migrant women is higher than that of Swiss women. However, migrant women from non-European countries are more likely to report having negative childbirth experiences than Swiss women. For example, during pregnancy, Chinese migrant mothers often felt dissatisfied with the follow-up pregnancy complications and lacked information on medical procedures and prenatal courses. In this paper, we explored their childbirth experiences in Swiss hospitals and how Swiss healthcare providers supported them.

METHOD

A qualitative study employing in-depth, semi-structured interviews was conducted with 14 Chinese mothers and 13 family members. All interviews were audio-recorded, transcribed, and translated into English for data analysis. Thematic analysis was employed to generate a detailed description.

RESULTS

Three main themes were extracted from the transcripts: (1) Sense of security, (2) Intrapartum care, and (3) Postpartum needs.

CONCLUSIONS

Our study shows Chinese migrant mothers prioritized giving birth in a physically and psychologically safe environment, with pain control and practical and emotional support from their intimate partners. They desired a physiological labor and birth with minimal obstetric interventions. Our research also reveals their postpartum needs, emphasizing the importance of postpartum support and obtaining culturally sensitive care during their postpartum hospital stay. The study adds new knowledge of specific migrant studies in Switzerland, as called for by the Swiss Federal Office of Public Health. The results call for the transcultural care skills training of Swiss healthcare providers to enable migrant women to have a more positive childbirth experience.

Labor Neuraxial Analgesia and Its Association With Perinatal Outcomes in China in 2015-2016: A Propensity Score-Matched Analysis

BACKGROUND

The use of labor neuraxial analgesia (NA) in China has increased significantly in the past decade, and the current rate of use is unknown. This study aimed to describe the epidemiology of NA based on a large multicenter cross-sectional survey, the China Labor and Delivery Survey (CLDS) (2015-2016), and to evaluate the association between NA and intrapartum caesarean delivery (CD) and maternal and neonatal outcomes.

METHODS

The CLDS was a facility-based cross-sectional investigation with a cluster random sampling scheme conducted from 2015 to 2016. A specific weight was assigned to each individual based on the sampling frame. Logistic regression was adopted to analyze the factors associated with the use of NA. A propensity score matching scheme was used to analyze the associations between NA and intrapartum CD and perinatal outcomes.

RESULTS

A total of 51,488 vaginal deliveries or intrapartum CD were included in our study, excluding prelabor CDs. The weighted NA rate was 17.3% (95% confidence interval [CI], 16.6-18.0) in this survey population. Nulliparous, previous CD, hypertensive disorders, and labor augmentation were associated with higher use of NA. In the propensity score-matched analysis, NA was associated with reduced risks of intrapartum CD, especially intrapartum CD by maternal request (adjusted odds ratio [aOR], 0.68; 95% CI, 0.60-0.78 and aOR, 0.48; 95% CI, 0.30-0.76, respectively), 3rd or 4th degree perineal laceration (aOR, 0.36; 95% CI, 0.15-0.89), and 5-minute Apgar score ≤3 (aOR, 0.15; 95% CI, 0.03-0.66).

CONCLUSIONS

The use of NA may be associated with improved obstetric outcomes, including fewer intrapartum CD, less birth canal trauma, and better neonatal outcomes in China.

Association of epidural analgesia during labor and early postpartum urinary incontinence among women delivered vaginally: a propensity score matched retrospective cohort study

BACKGROUND

Although epidural analgesia is considered the gold standard for pain relief during labor and is safe for maternity and fetus, the association between the epidural analgesia and pelvic floor disorders remains unclear. Thus we estimate the association between epidural analgesia and early postpartum urinary incontinence (UI).

METHODS

A propensity score-matched retrospective cohort study was conducted at a university-affiliated hospital in Shanghai, China. Primiparous women with term, singleton, and vaginal delivery between December 2020 and February 2022 were included. UI was self-reported by maternity at 42 to 60 days postpartum and was classified by International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF). Using logistic regression models, the associations between epidural analgesia and early postpartum UI were assessed.

RESULTS

Among 5190 participants, 3709 (71.5%) choose epidural anesthesia during labor. Analysis of the propensity-matched cohort (including 1447 maternal pairs) showed epidural anesthesia during labor was independently associated with UI in early postpartum period (aOR 1.50, 95% CI 1.24-1.81). This association was mainly contributed to stress UI (aOR 1.38, 95% CI 1.12-1.71) rather than urge UI (aOR 1.45, 95% CI 0.99-2.15) and mixed UI (aOR 1.52, 95% CI 0.95-2.45). Furthermore, we observed that the association between epidural anesthesia and UI was more pronounced among older women (≥ 35 y) and women with macrosomia (infant weight ≥ 4000 g), compared with their counterparts (both P for interaction < 0.01). After further analysis excluding the women with UI during pregnancy, the results remained largely consistent with the main analysis.

CONCLUSIONS

The findings support that epidural anesthesia was associated with SUI in the early postpartum period.

Association of labor epidural analgesia use with exclusive breastfeeding up to six months: a online-based cross sectional survey in Jiaxing, China

BACKGROUND

The impact of labor epidural analgesia (LEA) on breastfeeding remains controversial. The aim of this study was to assess the relationship between LEA use and exclusive breastfeeding (EBF) up to 6 months.

METHODS

This was a cross-sectional survey on healthy mothers who had vaginal delivery with infants aged 7-12 months from seven maternal health WeChat groups in Jiaxing, China. Data including EBF status up to 6 months, maternal sociodemographic characteristics, LEA use in labor, breastfeeding supports during hospitalization and reasons for stopping EBF were collected using online self-administered questionnaires in October 2021. A multivariable logistic regression model was used to determine the potential association of LEA use with EBF up to 6 months by the adjusted odds ratio (AOR) and 95% confidence interval (CI).

RESULTS

Of a total of 537 surveyed mothers, 408 (76.0%) delivered with LEA and 398 (74.1%) exclusively breastfed their infants until 6 months. All mothers delivered in the hospitals with active breastfeeding policies. There was no statistical difference in the rate of EBF up to 6 months between mothers with and without LEA (73.8% versus 75.2%, P = 0.748). Multivariable logistic regression analysis indicated that only increased maternal age (AOR = 0.906, 95% CI 0.854-0.961, P = 0.001) and perceived insufficient breast milk (AOR = 0.129, 95% CI 0.082-0.204, P <  0.001) were associated with lower odds of EBF up to 6 months. The top three reasons for non-EBF were no or insufficient breast milk (41.7%), inability to breastfeed infants after return to work (27.3%), and maternal related factors (24.4%).

CONCLUSIONS

LEA does not affect EBF up to 6 months. Other factors such as health education and breastfeeding-friendly hospital strategies may be much more important to breastfeeding outcomes compared to LEA use.

Scaling up of safety and quality improvement interventions in perioperative care: a systematic scoping review of implementation strategies and effectiveness

BACKGROUND

Globally, 5 billion people lack access to safe surgical care with more deaths due to lack of quality care rather than lack of access. While many proven quality improvement (QI) interventions exist in high-income countries, implementing them in low/middle-income countries (LMICs) faces further challenges. Currently, theory-driven, systematically articulated knowledge of the factors that support successful scale-up of QI in perioperative care in these settings is lacking. We aimed to identify all perioperative safety and QI interventions applied at scale in LMICs and evaluate their implementation mechanisms using implementation theory.

METHODS

Systematic scoping review of perioperative QI interventions in LMICs from 1960 to 2020. Studies were identified through Medline, EMBASE and Google Scholar. Data were extracted in two phases: (1) abstract review to identify the range of QI interventions; (2) studies describing scale-up (three or more sites), had full texts retrieved and analysed for; implementation strategies and scale-up frameworks used; and implementation outcomes reported.

RESULTS

We screened 45 128 articles, identifying 137 studies describing perioperative QI interventions across 47 countries. Only 31 of 137 (23%) articles reported scale-up with the most common intervention being the WHO Surgical Safety Checklist. The most common implementation strategies were training and educating stakeholders, developing stakeholder relationships, and using evaluative and iterative strategies. Reporting of implementation mechanisms was generally poor; and although the components of scale-up frameworks were reported, relevant frameworks were rarely referenced.

CONCLUSION

Many studies report implementation of QI interventions, but few report successful scale-up from single to multiple-site implementation. Greater use of implementation science methodology may help determine what works, where and why, thereby aiding more widespread scale-up and dissemination of perioperative QI interventions.

Evaluation efficacy and safety of epidural analgesia in second-trimester induced labor: A single-center, prospective, non-randomized, controlled study

BACKGROUND

Second-trimester induced labor in pregnant women was often more likely to suffer from psychological and physiological double pain. However, the analgesic management received less attention, and the optimal analgesic mode for second-trimester induced labor had not been determined. Our objective was to evaluate the feasible of epidural analgesia (EA) in second-trimester induced labor.

METHODS

From January 2020 to December 2021, Primipara who planned to undergo second-trimester induced labor in the First Affiliated Hospital of Yangtze University were collected. The method of labor induction was oral mifepristone + amniotic cavity injection of Ethacridine Lactate. Based on whether or not patients received epidural analgesia, which were divided into EA group (30 cases) and non-EA (NEA) group (30 cases). The primary outcome were visual analog scale (VAS) score of pain and result of follow-up, the secondary outcomes included relative clinical parameter and labor duration.

RESULTS

Vaginal induction of labor was successful in both groups. There was no statistically significant difference in VAS of pain between the two groups before analgesia (P > .05), but the VAS of pain in the EA group was significantly lower than the NEA group (P < .05) after analgesia or at delivery. The following outcomes showed no statistical difference between two groups: labor duration, postpartum hemorrhage, hemorrhage ≥ 500 mL, intrapartum injury, second days hemoglobin, C-reactive protein, antibiotic therapy days, hospitalizations days, and placenta residue (P > .05). The median hospitalization costs of EA group was 4697.5 yuan, and NEA group was 3673 yuan, the difference was statistically significant (P < .001). No adverse events related to EA occurred during hospitalization, only 3 patients showed mild lumbago and back pain after follow-up to three months postpartum, which was significantly relieved after proper rest.

CONCLUSION

EA can significantly reduce the pain of parturients, which may be effective and safe in the second-trimester induced labor.

Factors Influencing the Implementation of Foreign Innovations in Organization and Management of Health Service Delivery in China: A Systematic Review

Background: China has been encouraged to learn from international innovations in the organization and management of health service delivery to achieve the national health reform objectives. However, the success and effectiveness of implementing innovations is affected by the interactions of innovations with the Chinese context. Our aim is to synthesize evidence on factors influencing the implementation of non-Chinese innovations in organization and management of health service delivery in mainland China. Methods: A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched seven databases for peer-reviewed articles published between 2009 and 2020. Data were analyzed and combined to generate a list of factors influencing the implementation of foreign innovations in China. The factors were classified in the categories context, system, organization, innovation, users, resources, and implementation process. Results: The 110 studies meeting the inclusion criteria revealed 33 factors. Most supported by evidence is the factor integration in organizational policies, followed by the factors motivation & incentives and human resources. Some factors (e.g., governmental policies & regulations) were mentioned in multiple studies with little or no evidence. Conclusion: Evidence on factors influencing the implementation of foreign innovations in organization and management of health service delivery is scarce and of limited quality. Although many factors identified in this review have also been reported in reviews primarily considering Western literature, this review suggests that extrinsic motivation, financial incentives, governmental and organizational policies & regulations are more important while decentralization was found to be less important in China compare to Western countries. In addition, introducing innovations in rural China seems more challenging than in urban China, because of a lack of human resources and the more traditional rural culture.

Evaluation of Epidural Analgesia Use During Labor and Infection in Full-term Neonates Delivered Vaginally

IMPORTANCE

Quantification of potential consequences associated with the use of epidural analgesia during labor could help to improve the safety and quality of labor and delivery care for parturient women.

OBJECTIVE

To evaluate the association between epidural analgesia use during labor and neonatal infection in a large cohort of parturient women.

DESIGN, SETTING, AND PARTICIPANTS

This propensity score-matched cohort study was conducted at a university-affiliated hospital in Shanghai, China. Women at full-term pregnancy undergoing vaginal delivery between January 2013 and October 2018 were included in the study. Parturient women who were parous, experiencing premature delivery (gestational age <37 weeks), were pregnant with more than 1 fetus, or had experienced a stillbirth were excluded. Data were analyzed from October 2019 to June 2020.

EXPOSURES

The use of epidural analgesia during labor.

MAIN OUTCOMES AND MEASURES

The primary outcome was the incidence of neonatal infection, including neonatal sepsis, neonatal uncharacterized infection, neonatal pneumonia, and neonatal necrotizing enterocolitis reported in the medical record. Secondary outcomes included the incidence of maternal intrapartum fever and histologic chorioamnionitis.

RESULTS

Among 37 786 parturient women included (mean [SD] age, 29.5 [3.0] years), 19 968 (52.8%) received epidural analgesia during labor. In the propensity score-matched cohort (including 15 401 parturient women in each group), use of epidural analgesia was associated with a higher incidence of neonatal infection (absolute risk difference, 2.6%, 95% CI, 2.2%-3.0%; relative risk [RR], 2.43; 95% CI, 2.11-2.78), including higher incidence of sepsis (absolute risk difference, 0.1%, 95% CI, 0.1%-0.2%; RR, 3.50; 95% CI, 1.73-7.07) and uncharacterized infection (absolute risk difference, 2.2%, 95% CI, 1.9% to 2.6%; RR, 2.69; 95% CI, 2.30-3.15), compared with no epidural analgesia use. Use of epidural analgesia was also associated with greater incidence of maternal intrapartum fever (RR, 4.12; 95% CI, 3.78-4.50) and histologic chorioamnionitis (RR, 4.08; 95% CI, 3.59-4.64) compared with no epidural analgesia use.

CONCLUSIONS AND RELEVANCE

This cohort study found that use of epidural analgesia in full-term nulliparous women undergoing vaginal delivery was associated with an increased risk of neonatal infection, pending further investigation. These findings support efforts to further improve safety and quality of labor and delivery care for parturient women.

Why is the labor epidural rate low and cesarean delivery rate high? A survey of Chinese perinatal care providers

Objective

China has a high cesarean delivery (CD) and low labor epidural analgesia (LEA) rate. This online survey was conducted to explore the reasons behind this phenomenon and potential solutions.

Methods

A voluntary, anonymous survey was distributed via both WeChat and professional websites for 4 months amongst groups of Chinese perinatal professionals. Data was collected and analyzed using a Chi-square test and presented as percentages of respondents.

Results

1412 respondents were recorded (43% anesthesiologists, 35% obstetricians, 15.5% midwives or labor and delivery nurses, and 6.5% others), and 1320 respondents were care providers. It was found that 82.7% (1092/1320) of the provider respondents used CD per patient request in fear of lawsuits or yinao/yibao and 63.4% (837/1320) used CD for respecting superstitious culture. The number one reason (noted by 60.2% (795/1320) of all the three specialties) for low LEA use was lack of anesthesia manpower without statistical difference among specialties. The most recommended solution was increasing the anesthesia workforce, proposed by 79.8% (1053/1320) of the three specialties. However, the top solution provided by the two non-anesthesia specialties is different from the one proposed by anesthesiologists. The later (83%, 504/606) suggested increasing the incentive to provide the service is more effective. The answers to questions related to medical knowledge about CD and LEA, and unwillingness of anesthesiologists, parturients and their family members to LEA were similar for the most part, while the opinions regarding low LEA use related to poor experiences and unwillingness of obstetricians and hospital administrators were significantly divided among the three specialties. In the providers’ point of view, the unwillingness to LEA from parturient’s family members was the most salient (26.1%, 345/1320), which is more than all care providers, hospital administrators, and parturients themselves (16.8%, 222/1320).

Conclusion

The reasons for high CD rate and low LEA use are multifactorial. The sociological issues (fear of yinao/yibao and superstitious culture) were the top two contributing factors for the high CD rate in China, while lack of anesthesia manpower was the top response for the low LEA use, which contributes to its being the most recommended solution overall from the three specialties. An incentive approach to providers is a short-term solution while training more perinatal care providers (especially among anesthesiologists and midwives), improving billing systems, and reforming legal systems are 3 systemic approaches to tackling this problem in the long-term.

The trends and associated adverse maternal and perinatal outcomes of labour neuraxial analgesia among vaginal deliveries in China between 2012 and 2019: a real-world observational evidence

BACKGROUND

There is a lack of national report of the labour neuraxial analgesia (NA) rates in China in recent years, especially after the national promotion policy. The adverse maternal and perinatal outcomes associated with NA in China are also unknown. The aim of this study is to estimate the trends of NA rates from 2012 to 2019, to evaluate the effect of national policy on promoting NA and to identify the association between NA and adverse outcomes in China.

METHODS

We used the individual data from China's National Maternal Near Miss Surveillance System (NMNMSS) between 2012 and 2019, covering 438 hospitals from 326 urban districts or rural counties in 30 provinces across China. The analysis was restricted to singleton pregnant women who underwent vaginal delivery at or after 28 completed weeks of gestation. We estimate the trends of NA rates between 2012 and 2019, both at the national and provincial levels using Bayesian multilevel model. We also estimated the effect of the national pilot policy launched in 2018 using interrupted time-series analysis and identified the association between NA and adverse outcomes using modified Poisson regression combined with propensity score analysis.

RESULTS

Over the study period, 620,851 of 6,023,046 women underwent vaginal delivery with NA. The estimated national NA rates increased from 8.4% in 2012 to 16.7% in 2019. Most provinces experienced the same rapid rise during this period. The national pilot policy accelerated the rise of the rates. No differences were observed between women with NA and without any analgesia in the incidence of uterine atony, placental retention, intrapartum stillbirths and 1- and 5-min Apgar scores lower than 7. However, women with NA had higher incidences of genital tract trauma (adjusted relative risk (aRR) 1.53, 95% confidence interval (CI) 1.04-2.26) and maternal near miss (aRR 1.35, 95% CI 1.08-1.69), only in hospitals which were not covered by the national pilot policy and usually lack of sufficient equipment and personnel.

CONCLUSIONS

The national policy can effectively increase the NA rate. However, as genital tract trauma and maternal near miss may increase in low-resource hospitals, but not in high-resource hospitals, further study is required to identify the reasons.

The Effect of the No Pain Labor & Delivery-Global Health Initiative on Cesarean Delivery and Neonatal Outcomes in China: An Interrupted Time-Series Analysis

BACKGROUND

The proportion of live births by cesarean delivery (CD) in China is significant, with some, particularly rural, provinces reporting up to 62.5%. The No Pain Labor & Delivery-Global Health Initiative (NPLD-GHI) was established to improve obstetric and neonatal outcomes in China, including through a reduction of CD through educational efforts. The purpose of this study was to determine whether a reduction in CD at a rural Chinese hospital occurred after NPLD-GHI. We hypothesized that a reduction in CD trend would be observed.

METHODS

The NPLD-GHI program visited the Weixian Renmin Hospital, Hebei Province, China, from June 15 to 21, 2014. The educational intervention included problem-based learning, bedside teaching, simulation drill training, and multidisciplinary debriefings. An interrupted time-series analysis using segmented logistic regression models was performed on data collected between June 1, 2013 and May 31, 2015 to assess whether the level and/or trend over time in the proportion of CD births would decline after the program intervention. The primary outcome was monthly proportion of CD births. Secondary outcomes included neonatal intensive care unit (NICU) admissions and extended NICU length of stay, neonatal antibiotic and intubation use, and labor epidural analgesia use.

RESULTS

Following NPLD-GHI, there was a level decrease in CD with an estimated odds ratio (95% confidence interval [CI]) of 0.87 (0.78-0.98), P = .017, with odds (95% CI) of monthly CD reduction an estimated 3% (1-5; P < .001), more in the post- versus preintervention periods. For labor epidural analgesia, there was a level increase (estimated odds ratio [95% CI] of 1.76 [1.48-2.09]; P < .001) and a slope decrease (estimated odds ratio [95% CI] of 0.94 [0.92-0.97]; P < .001). NICU admissions did not have a level change (estimated odds ratio [95% CI] of 0.99 [0.87-1.12]; P = .835), but the odds (95% CI) of monthly reduction in NICU admission was estimated 9% (7-11; P < .001), greater in post- versus preintervention. Neonatal intubation level and slope changes were not statistically significant. For neonatal antibiotic administration, while the level change was not statistically significant, there was a decrease in the slope with an odds (95% CI) of monthly reduction estimated 6% (3-9; P < .001), greater post- versus preintervention.

CONCLUSIONS

In a large, rural Chinese hospital, live births by CD were lower following NPLD-GHI and associated with increased use of labor epidural analgesia. We also found decreasing NICU admissions. International-based educational programs can significantly alter practices associated with maternal and neonatal outcomes.

Evaluation of cesarean delivery rates in different levels of hospitals in Jiangsu Province, China, using the 10-Group classification system

OBJECTIVE

To compare cesarean delivery (CD) rates in referral and non-referral hospitals in Maternal Safety Collaboration in Jiangsu province, China.

METHODS

Sixteen participants (4 referral hospitals, 12 non-referral hospitals) from Drum Tower Hospital Collaboration for Maternal Safety reported CD rates in 2019 using ten-group classification system and maternal/neonatal morbidity and mortality.

RESULTS

A total of 22,676 CDs were performed among 52,499 deliveries and the average CD rate was 43.2% (range 34.8-69.6%). CD rate in non-referral hospitals (44.7%) was significantly higher than it was in referral hospitals (40.4%, p < .001). Term singleton cephalic nulliparous women with spontaneous labor (Group 1) or induced labor (Group 2a) had higher CD rates if they were cared in non-referral hospitals compared with those in referral hospitals (Group 1: 11.8% vs. 4.4%, p < .001; Group 2a: 29.1% vs. 21.3%, p < .001). In non-referral hospitals, CD rate in Group 5 and the proportion of Group 5 to the overall population were also significantly higher than those in referral hospitals (98.5% vs. 92.5%, p < .001; and 21.0% vs. 14.5%, p < .001).

CONCLUSION

To decrease the CD rate, we need to take efforts in decreasing unnecessary operations for term singleton cephalic nulliparous women and increasing the rate of trial of labor after CD.

Concerned topics of epidural labor analgesia: labor elongation and maternal pyrexia: a systematic review

Objective:

Labor is a complex process and labor pain presents challenges for analgesia. Epidural analgesia (EA) has a well-known analgesic effect and is commonly used during labor. This review summarized frequently encountered and controversial problems surrounding EA during labor, including the labor process and maternal intrapartum fever, to build knowledge in this area.

Data sources:

We searched for relevant articles published up to 2019 in PubMed using a range of search terms (eg, “labor pain,” “epidural,” “analgesia,” “labor process,” “maternal pyrexia,” “intrapartum fever”).

Study selection:

The search returned 835 articles, including randomized control trials, retrospective cohort studies, observational studies, and reviews. The articles were screened by title, abstract, and then full-text, with a sample independently screened by two authors. Thirty-eight articles were included in our final analysis; 20 articles concerned the labor process and 18 reported on maternal pyrexia during EA.

Results:

Four classic prospective studies including 14,326 participants compared early and delayed initiation of EA by the incidence of cesarean delivery. Early initiation following an analgesia request was preferred. However, it was controversial whether continuous use of EA in the second stage of labor induced adverse maternal and neonatal outcomes due to changes in analgesic and epidural infusion regimens. There was a high incidence of maternal pyrexia in women receiving EA and women with placental inflammation or histologic chorioamnionitis compared with those receiving systemic opioids.

Conclusions:

Early EA (cervical dilation ≥1 cm) does not increase the risk for cesarean section. Continuous epidural application of low doses of analgesics and programmed intermittent epidural bolus do not prolong second-stage labor duration or impact maternal and neonatal outcomes. The association between EA and maternal pyrexia remains controversial, but pyrexia is more common with EA than without. A non-infectious inflammatory process is an accepted mechanism of epidural-related maternal fever.

Benefits and risks of upright positions during the second stage of labour: An overview of systematic reviews

BACKGROUND

Upright positions during the second stage of labour are assumed to have many physiological advantages that may facilitate normal birth. Clarifying the underlying benefits and risks of upright positions plays an important role in the implementation of upright positions. The benefits and risks of upright positions during the second stage of labour have been explored in several systematic reviews, but the results are divergent.

OBJECTIVE

To summarize the evidence on the underlying benefits and risks of upright positions during the second stage of labour by searching available systematic reviews to explore the best evidence for clinical practice and decision making.

DESIGN

Overview of systematic reviews.

DATA SOURCES

We systematically searched five English databases and four Chinese databases from inception to 15th March 2020 for any published and ongoing systematic reviews.

REVIEW METHODS

Two reviewers independently evaluated the methodological and the reporting quality of the included systematic reviews using the AMSTAR 2 tool and the PRISMA checklist. A descriptive synthesis was used by reporting the results of the highest quality reviews.

RESULTS

Seven systematic reviews met the eligibility criteria, of which two Cochrane reviews had the highest methodological and reporting quality. In women without epidural analgesia, upright positions significantly reduced the rate of instrumental vaginal birth (moderate-quality evidence), shortened the second stage of labour (very low-quality evidence), reduced the rate of episiotomy (very low-quality evidence) and abnormal foetal heart rate patterns requiring intervention (very low-quality evidence), but significantly increased the risk of blood loss greater than 500 ml (moderate-quality evidence) and second-degree perineal trauma (low-quality evidence). However, no definite benefits or risks of upright positions were found in women with epidural analgesia based on the current evidence.

CONCLUSIONS

This overview demonstrates that upright positions have both benefits and risks but the quality of the current evidence is relatively low. It is necessary for the researchers to conduct robust studies to provide stronger evidence. In addition, upright positions are recommended to be used depending on women's preferences and labour progress, but should also be carefully monitored especially in women with epidural analgesia. Registration number: CRD42020175820.

Women's experience of psychological birth trauma in China: a qualitative study

BACKGROUND

The psychological birth trauma is a universal phenomenon in childbearing women. The influences could extend in a wide range, which includes the mothers' health, mother-infant relationship, partner relationship. The medical staff could even choose to quit playing their part in the birthing process. The phenomenon has gradually garnered attention around the world. However, it has rarely been discussed under Chinese special conditions. The study was to explore Chinese women's lived experiences of psychological birth trauma during labor and birth.

METHODS

A descriptive phenomenological approach was adopted in this study. Twenty-four women were recruited, who reported having experienced psychological birth trauma. In-depth interviews were conducted within 1 week after birth. Colaizzi's method was used to analyze the data.

RESULTS

Twenty-four women participated in the study. Four themes emerged to describe the women's experience of psychological birth trauma: "How am I supposed to relieve the endless pain?" " Can't I be weak?" "Am I not important?" "What uncertainties are waiting for me?"

CONCLUSIONS

The findings provide deep insight into Chinese women's unique experience of psychological birth trauma. The social and health system could prevent psychological harm during birth and promote maternal health by measures of pain management, thoughtful attention, adequate caring, and prenatal preparation.

The effect of initiating neuraxial analgesia service on the rate of cesarean delivery in Hubei, China: a 16-month retrospective study

BACKGROUND

No Pain Labor &Delivery (NPLD) is a nongovernmental project to increase access to safe neuraxial analgesia through specialized training. This study explores the change in overall cesarean delivery (CD) rate and maternal request CD(MRCD) rate in our hospital after the initiation of neuraxial analgesia service (NA).

METHODS

NA was initiated in May 1st 2015 by the help of NPLD. Since then, the application of NA became a routine operation in our hospital, and every parturient can choose to use NA or not. The monthly rates of NA, CD, MRCD, multiparous women, intrapartum CD, episiotomy, postpartum hemorrhage (PPH), operative vaginal delivery and neonatal asphyxia were analyzed from January 2015 to April 2016.

RESULTS

The rate of NA in our hospital was getting increasingly higher from 26.1% in May 2015 to 44.6% in April 2016 (p < 0.001); the rate of CD was 48.1% (3577/7360) and stable from January to May 2015 (p>0.05), then decreased from 50.4% in May 2015 to 36.3% in April 2016 (p < 0.001); the rate of MRCD was 11.4% (406/3577) and also stable from January to May 2015 (p>0.05), then decreased from 10.8% in May 2015 to 5.7% in April 2016 (p < 0.001). At the same time, the rate of multiparous women remained unchanged during the 16 month of observation (p>0.05). There was a negative correlation between the rate of NA and rate of overall CD, r = - 0.782 (95%CI [- 0.948, - 0.534], p<0.001), and between the utilization rate of NA and rate of MRCD, r = - 0.914 (95%CI [- 0.989, - 0.766], p<0.001). The rates of episiotomy, PPH, operative vaginal delivery and neonatal asphyxia in women who underwent vaginal delivery as well as the rates of intrapartum CD, neonatal asphyxia, and PPH in women who underwent CD remained unchanged, and there was no correlation between the rate of NA and anyone of those rates from January 1st 2015 to April 30th 2016 (p>0.05).

CONCLUSIONS

Our study shows that the rates of CD and MRCD in our department were significantly decreased from May 1st 2015 to April 30th 2016, which may be due to the increasing use of NA during vaginal delivery with the help of NPLD.

Effect of China's Universal Two-child Policy on the Rate of Cesarean Delivery: A Case Study of a Big Childbirth Center in China

China's universal two-child policy was released in October of 2015. How would this new policy influence the rate of overall cesarean delivery (CD) in China? The objective of this paper is to investigate the trend of overall CD rate with the increase of number of multiparous women based on a big childbirth center of China (a tertiary hospital) in 2016. In this study, 22 530 cases from the medical record department of a big childbirth center of China from January 1 to December 31 in 2016 were enrolled as research objects. Electronic health records of these selected objects were retrieved. According to the history of childbirth, the selected cases were divided into primiparous group containing 16 340 cases and multiparous group containing 6190 cases. Chi-square test was carried out to compare the rate of CD, neuraxial labor analgesia, maternity insurance between the two groups; t-test was performed to compare the in-hospital days and gestational age at birth between the two groups. Pearson correlation coefficient was used to evaluate the relationship among observed monthly rate of multiparas, overall CD rate, and Elective Repeat Cesarean Delivery (ERCD) rate. The results showed that the CD rate in multiparous group was 55.46%, which was higher than that in primiparous group (34.66%, P<0.05). The rate of neuraxial labor analgesia in multiparas group was 9.29%, which was lower than that in primiparas group (35.94%, P<0.05). However, the rate of maternity insurance was higher in multiparas group (57.00%) than that in primiparas group (41.08%, P<0.05). The hospital cost and in-hospital days in multiparas group were higher, and the gestational age at birth in multiparas group was lower than in primiparas group (P<0.05). The overall CD rate slightly dropped in the first 4 months of the year (P<0.05), then increased from 36.27% (April) to 43.21% (December) (P<0.05). The rate of multiparas women and ERCD had the same trend (P<0.05). There were linear correlations among the rate of overall CD, the rate of multiparas women and the rate of ERCD rate (P<0.05). With the opening of China's two-child policy, the increasing rate of overall CD is directly related with the high rate of ERCD. Trials of Labor After Cesarean Section (TOLAC) in safe mode to reduce overall CD rate are warranted in the future.

Are there differences in pain intensity between two consecutive vaginal childbirths? A retrospective cohort study

BACKGROUND

Pain assessment is crucial for in-labour pain management. Even though women's self-rated pain intensity is the standard for pain relief or analgesic administration, multiparas appear to receive worse in-labour pain management than primiparas do. The discrepancy in pain perception between primiparas and multiparas remains unclear. Healthcare providers tend to think that multiparas endure the pain and report less pain because they have experienced childbirth.

OBJECTIVE

To retrospectively analyse the intensity of in-labour pain during first and second vaginal childbirth within the same group of women and explore whether parity may be an influential factor in labour pain intensity.

DESIGN

Retrospective cohort study.

SETTING

Labour and delivery in a large academic specialized hospital in Guangzhou, China.

PARTICIPANTS

Women were included if they had two consecutive vaginal childbirths with singleton cephalic presentations and cervical dilation ≤ 3 cm for the first childbirth and ≤ 2 cm for the second childbirth. The final study sample consisted of 417 women.

METHODS

All childbirth case records between January 2015 and August 2018 were scanned using a structured electronic medical system. Maternal and neonatal demographics as well as obstetric and neonatal outcomes were extracted. The in-labour pain for each childbirth was compared between first and second births. Paired t-tests, McNemar's chi-square tests and mixed-effects modelling were applied to compare the differences in labour pain intensity between the two vaginal childbirths and explore the factors that influenced maximum labour pain scores during the second childbirth.

RESULTS

Four hundred seventeen women were included, with an average birth interval of 1.7 years. The average maximum labour pain score during the latent phase was 6 (5,6) for the first childbirth and 5 (4,6) for the second childbirth (paired t =-6.13, P <0.001). Pain scores decreased in 28.1% (117/417) of women and increased in 13.7% (57/417) of women from the first to the second childbirth. More than half of the women in our study experienced the same maximum labour pain score during the first and second labour. Mixed-effects modelling revealed that parity, education and pregnancy complications were independently associated with maximum labour pain scores.

CONCLUSIONS

From a clinical point of view, in-labour pain is not clinically different for women when comparing their first and second labours. Health care professionals may underestimate in-labour pain in primiparas when comparing them with nulliparas. More studies are warranted to explore options for achieving better pain management for women with more childbirths.

Interventions to reduce the cesarean delivery rate in a tertiary hospital in China

Introduction: High cesarean delivery rate has been a global public health concern. This study assesses the effect of medical interventions and societal changes on cesarean delivery rates in a Chinese tertiary hospital.Material and methods: A retrospective study including all live births ≥34-week gestation between 2008 and 2016 from Guangzhou Women and Children's Medical Center was divided into 5 stages: (1) no interventions; (2) patient-controlled epidural analgesia; (3) episiotomy restriction; (4) new labor management; (5) universal two-child policy. An interrupted time series design was used to measure the effect of interventions on overall cesarean rate, primary cesarean rate, maternal and neonatal outcomes.Results: There were 126,609 deliveries including 49,092 cesarean deliveries and 77,517 vaginal deliveries in this period. Overall cesarean delivery rate declined after implementing patient-controlled epidural analgesia, episiotomy restriction and universal two-child policy. Primary cesarean rate decreased after implementing episiotomy restriction. Cesarean rate with previous cesarean dramatically increased, and maternal request cesarean rate decreased gradually. Low Apgar rate (score ≤7 at 5 min) increased after episiotomy restriction and maternal postpartum hemorrhage rate increased after new labor management.Conclusions: Patient-controlled epidural analgesia, episiotomy restriction and the universal two-child policy showed the most significant effects to reducing the cesarean rate.

Impact of epidural analgesia during labor on breastfeeding initiation and continuation: a retrospective study

Objective: Although epidural analgesia is widely used during labor, its impact on breastfeeding has not yet reached a consensus. This retrospective cohort study was to investigate the association of patient-controlled epidural analgesia (PCEA) during labor with breastfeeding initiation and continuation.Methods: Medical records from 1 February, 2016 to 31 December, 2016 at Guangzhou Women and Children's Medical Center, China were reviewed for women received PCEA or not. Breastfeeding continuation was assessed by a questionnaire at 6 months after hospital discharge.Results: Nine hundred twenty-two women were enrolled in the study, with 527 of these women received PCEA for labor analgesia. The proportion of timely initiation of breastfeeding (within 1 h after birth), and exclusive or partial breastfeeding at any of the evaluation time points (1, 3, and 6 months) between two groups showed no statistically significant difference.Conclusion: Our data do not support an association between the PCEA and discontinuation of breastfeeding within 6 months postpartum.

Birth Tourism Among Chinese Women

PURPOSE

To explore the reasons why some Chinese women travel to the United States on a tourist visa specifically to give birth, also known as birth tourism.

STUDY DESIGN

Qualitative, exploratory design.

METHODS

Using convenience and snowball sampling, Chinese women were recruited from the waiting rooms of obstetricians known to care for birth tourists. Participants completed demographic data and provided answers to questions about their reasons for traveling to give birth and their birth experience while in the United States. Qualitative content analysis methods were used to extract themes from participant narratives.

RESULTS

Twelve married, college-educated women, aged between 26 and 39 years, self-identifying as birth tourists from China participated in this study. Content analysis revealed two themes: (1) positive perceptions of childbirth in the United States; and (2) securing a future for their child.

CLINICAL IMPLICATIONS

Study findings suggest Chinese birth tourists come to the United States for a better childbirth experience, and to secure future opportunities for their children. Nurses should be aware of the current political climate on immigration and birth tourism in order to promote a safe and judgment-free environment when providing care to this unique population of women.

Alterations in the Urinary Microbiota Are Associated With Cesarean Delivery

Similar to the gut, the bladder contains urinary microbiota, and its bacterial composition and structure are determined by the individual’s health status. Cesarean section is a traumatic event for women and it is correlated with postpartum complications. To better understand the urinary microbiota alterations caused by cesarean section, 16S rDNA sequencing was used to assess urine specimens collected by transurethral catheterization from 30 healthy women undergoing cesarean section pre-delivery (PreD) and post-delivery (PostD). A significant increase in bacterial diversity and more detectable bacteria at the phylum, family, and genus levels was observed in the PostD group compared to the PreD group, indicating that cesarean delivery (a process that includes surgery and delivery) altered the bacterial community. Specifically, the phylum Firmicutes and its affiliated family Lactobacillaceae and genus Lactobacillus dramatically decreased in the PostD group, suggesting that beneficial bacteria decreased after cesarean section, and clinicians should be aware that this might increase the risk of complications. Concurrently, the phylum Proteobacteria and its affiliated bacteria Pseudomonadaceae and Pseudomonas increased in the PostD group compared to the PreD group. This indicates that pathogen growth increases after cesarean section, making it important for clinicians to combat these changes to protect women from infectious diseases. Interestingly, several metabolic pathways, such as metabolism of energy, cofactors and vitamins were strengthened in the PostD group, whereas membrane transport was lessened in this group. This suggests that women’s metabolic disorders might be cured by balancing urinary microbiota. In conclusion, the altered urinary microbiota between the PreD and PostD periods appears to provide insight into how to prevent postpartum metabolic disorders.

Epidural versus non-epidural or no analgesia for pain management in labour

BACKGROUND

Epidural analgesia is a central nerve block technique achieved by injection of a local anaesthetic close to the nerves that transmit pain, and is widely used as a form of pain relief in labour. However, there are concerns about unintended adverse effects on the mother and infant. This is an update of an existing Cochrane Review (Epidural versus non-epidural or no analgesia in labour), last published in 2011.

OBJECTIVES

To assess the effectiveness and safety of all types of epidural analgesia, including combined-spinal-epidural (CSE) on the mother and the baby, when compared with non-epidural or no pain relief during labour.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (ClinicalTrials.gov), the WHO International Clinical Trials Registry Platform (ICTRP) (30 April 2017), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials comparing all types of epidural with any form of pain relief not involving regional blockade, or no pain relief in labour. We have not included cluster-randomised or quasi-randomised trials in this update.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risks of bias, extracted data and checked them for accuracy. We assessed selected outcomes using the GRADE approach.

MAIN RESULTS

Fifty-two trials met the inclusion criteria and we have included data from 40 trials, involving over 11,000 women. Four trials included more than two arms. Thirty-four trials compared epidural with opioids, seven compared epidural with no analgesia, one trial compared epidural with acu-stimulation, one trial compared epidural with inhaled analgesia, and one trial compared epidural with continuous midwifery support and other analgesia. Risks of bias varied throughout the included studies; six out of 40 studies were at high or unclear risk of bias for every bias domain, while most studies were at high or unclear risk of detection bias. Quality of the evidence assessed using GRADE ranged from moderate to low quality.Pain intensity as measured using pain scores was lower in women with epidural analgesia when compared to women who received opioids (standardised mean difference -2.64, 95% confidence interval (CI) -4.56 to -0.73; 1133 women; studies = 5; I2 = 98%; low-quality evidence) and a higher proportion were satisfied with their pain relief, reporting it to be "excellent or very good" (average risk ratio (RR) 1.47, 95% CI 1.03 to 2.08; 1911 women; studies = 7; I2 = 97%; low-quality evidence). There was substantial statistical heterogeneity in both these outcomes. There was a substantial decrease in the need for additional pain relief in women receiving epidural analgesia compared with opioid analgesia (average RR 0.10, 95% CI 0.04 to 0.25; 5099 women; studies = 16; I2 = 73%; Tau2 = 1.89; Chi2 = 52.07 (P < 0.00001)). More women in the epidural group experienced assisted vaginal birth (RR 1.44, 95% CI 1.29 to 1.60; 9948 women; studies = 30; low-quality evidence). A post hoc subgroup analysis of trials conducted after 2005 showed that this effect is negated when trials before 2005 are excluded from this analysis (RR 1.19, 95% CI 0.97 to 1.46). There was no difference between caesarean section rates (RR 1.07, 95% CI 0.96 to 1.18; 10,350 women; studies = 33; moderate-quality evidence), and maternal long-term backache (RR 1.00, 95% CI 0.89 to 1.12; 814 women; studies = 2; moderate-quality evidence). There were also no clear differences between groups for the neonatal outcomes, admission to neonatal intensive care unit (RR 1.03, 95% CI 0.95 to 1.12; 4488 babies; studies = 8; moderate-quality evidence) and Apgar score less than seven at five minutes (RR 0.73, 95% CI 0.52 to 1.02; 8752 babies; studies = 22; low-quality evidence). We downgraded the evidence for study design limitations, inconsistency, imprecision in effect estimates, and possible publication bias.Side effects were reported in both epidural and opioid groups. Women with epidural experienced more hypotension, motor blockade, fever, and urinary retention. They also had longer first and second stages of labour, and were more likely to have oxytocin augmentation than the women in the opioid group. Women receiving epidurals had less risk of respiratory depression requiring oxygen, and were less likely to experience nausea and vomiting than women receiving opioids. Babies born to women in the epidural group were less likely to have received naloxone. There was no clear difference between groups for postnatal depression, headache, itching, shivering, or drowsiness. Maternal morbidity and long-term neonatal outcomes were not reported.Epidural analgesia resulted in less reported pain when compared with placebo or no treatment, and with acu-stimulation. Pain intensity was not reported in the trials that compared epidural with inhaled analgesia, or continuous support. Few trials reported on serious maternal side effects.

AUTHORS' CONCLUSIONS

Low-quality evidence shows that epidural analgesia may be more effective in reducing pain during labour and increasing maternal satisfaction with pain relief than non-epidural methods. Although overall there appears to be an increase in assisted vaginal birth when women have epidural analgesia, a post hoc subgroup analysis showed this effect is not seen in recent studies (after 2005), suggesting that modern approaches to epidural analgesia in labour do not affect this outcome. Epidural analgesia had no impact on the risk of caesarean section or long-term backache, and did not appear to have an immediate effect on neonatal status as determined by Apgar scores or in admissions to neonatal intensive care. Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia and non-epidural analgesia on women in labour and long-term neonatal outcomes.

Providing anesthesia in resource-limited settings

PURPOSE OF REVIEW

The article reviews the reality of anesthetic resource constraints in low and middle-income countries (LMICs). Understanding these limitations is important to volunteers from high-income countries who desire to teach or safely provide anesthesia services in these countries.

RECENT FINDINGS

Recently published information on the state of anesthetic resources in LMICs is helping to guide humanitarian outreach efforts from high-income countries. The importance of using context-appropriate anesthesia standards and equipment is now emphasized. Global health experts are encouraging equal partnerships between anesthesia health care providers working together from different countries. The key roles that ketamine and regional anesthesia play in providing well tolerated anesthesia for cesarean sections and other common procedures is increasingly recognized.

SUMMARY

Anesthesia can be safely given in LMICs with basic supplies and equipment, if the anesthesia provider is trained and vigilant. Neuraxial and regional anesthesia and the use of ketamine as a general anesthetic appear to be the safest alternatives in low-resource countries. Environmentally appropriate equipment should be encouraged and pulse oximeters should be in every anesthetizing location. LMICs will continue to need support from outside sources until capacity building has made more progress.

Prediction of vaginal birth after cesarean delivery in Chinese parturients

There is an urgent need in China to better predict vaginal birth after cesarean (VBAC) to face the challenge of the second child policy. We aimed to validate a widely used VBAC prediction model (Grobman's model) and a modified version of this model in a Chinese population. In this retrospective cohort study, 444 women with one cesarean delivery and at least one subsequent attempt for a trial of labor in Nanjing, China were included. The considered potential VBAC predictors included Grobman's background variables and five new variables. Overall, a total of 370 women had VBAC, with a success rate of 83.3%. The new background variables "maternal height" and "estimated fetal weight" were considered as two additional predictors for VBAC. The AUC of Grobman's model was 0.831 (95%CI = 0.775-0.886) while the AUC of our modified model with two new variables added was 0.857 (sensitivity = 72.2%, specificity = 83.8%). However, the difference between the AUC of the two models was not significant (Z = -1.69, P = 0.091). We confirmed that Grobman's model was accepted in the Chinese population. A modified model that is supplemented with maternal height and estimated fetal weight needs to be further studied in the Chinese population.

New medical risks affecting obstetrics after implementation of the two-child policy in China

China recently instituted a two-child policy in response to its aging population, declining workforce and demographic dividend, and the need to develop asocial economy. Additionally, women generally delay having a second child because of the overwhelming pressure in their lives. With the improvements in assisted fertility technologies in recent years, the number of elderly women attempting to bear children has increased. The quality of woman's eggs and a man's sperm declined dramatically with increasing age, leading to an increased risk of pregnancy-related complications among older women. Therefore, the types of fertility problems experienced by elderly females must be provided with considerable attention by obstetricians. This commentary article focuses on the medical problems faced by older second-child pregnant women. This work discusses their increased rates of infertility, spontaneous abortion, fetal malformation, gestational diabetes, cesarean section, placenta previa, postpartum hemorrhage, postpartum depression, and hypertensive disorders, which complicate pregnancy.

Establishing Obstetric Anesthesiology Practice Guidelines in the Republic of Armenia: A Global Health Collaboration

BACKGROUND

Disparity exists in anesthesia practices between high- and low-to-middle income countries, and awareness has been raised within the global health community to improve the standards of anesthesia care and patient safety. The establishment of international collaborations and appropriate practice guidelines may help address clinical care deficiencies. This report's aim was to assess the impact of a multiyear collaboration on obstetric anesthesia practices in the Republic of Armenia.

METHODS

An invited multinational team of physicians conducted six visits to Armenia between 2006 and 2015 to observe current practice and establish standards of obstetric anesthesia care. The Armenian Society of Anaesthesiologists and Intensive Care specialists collected data on the numbers of vaginal delivery, cesarean delivery, and neuraxial anesthesia use in maternity units during the period. Data were analyzed with the Fisher exact or chi-square test, as appropriate.

RESULTS

Neuraxial anesthesia use for cesarean delivery increased significantly (P < 0.0001) in all 10 maternity hospitals within the capital city of Yerevan. For epidural labor analgesia, there was sustained or increased use in only two hospitals. For hospitals located outside the capital city, there was a similar increase in the use of neuraxial anesthesia for cesarean delivery that was greater in hospitals that were visited by an external team (P < 0.0001); however, use of epidural labor analgesia was not increased significantly. Over the course of the collaboration, guidelines for obstetric anesthesia were drafted and approved by the Armenian Ministry of Health.

CONCLUSIONS

Collaboration between Armenian anesthesiologists and dedicated visiting physicians to update and standardize obstetric anesthesia practices led to national practice guidelines and sustained improvements in clinical care in the Republic of Armenia.

Increasing Regional Anesthesia Use in a Serbian Teaching Hospital through an International Collaboration

Many low- and middle-income countries (LMICs) report low rates of regional anesthesia (RA) use for cesarean delivery (CD), despite its association with lower maternal major morbidity and mortality. Also, the prevalence of neuraxial analgesia for labor (NAL) is often low in LMICs. We report on the results of a collaboration in clinical education over a multi-year period between Kybele Inc., an international non-profit organization, and Klinicki Centar Vojvodine (CCV), a teaching hospital in Novi Sad, Serbia, to increase RA use for CD and NAL at CCV. From late 2011 through 2015, teams from Kybele participated in annual to biannual didactic conferences and week-long bedside teaching efforts involving obstetric and anesthesia staff from CCV and surrounding hospitals. Ongoing contact occurred at least weekly between Kybele and the host to discuss progress. De-identified quality improvement data on total deliveries, numbers of elective and non-elective CDs, number of vaginal deliveries, type of anesthesia for CD, and the number of NALs were collected. RA use for CD increased to 25% in year 2015 versus 14% in base year 2011 [odds ratio (OR): 2.05; 95% confidence interval (CI): 1.73,2.42; p < 0.001]. NAL increased to 10.5% of laboring women in 2015 versus 1.2% in 2011 (OR: 9.6; 95% CI: 7.2, 12.8; p < 0.001). Greater increases for RA use during non-elective CD were observed between 2011 and 2015 (1.4 versus 7.5% of total CD; OR: 5.52; 95% CI: 2.63, 8.41; p < 0.001) relative to elective CD (12.5 versus 17.5% of total CD; OR: 1.48; 95% CI: 1.23, 1.77; p < 0.001). Overall, RA for CD increased during the 4 year collaboration but was not as great as reported in other countries with similar health-care demographics utilizing a similar program. Detailed descriptions of program interventions and barriers to change at CCV are presented.

Requests for cesarean deliveries: The politics of labor pain and pain relief in Shanghai, China

Cesarean section rates have risen dramatically in China within the past 25 years, particularly driven by non-medical factors and maternal requests. One major reason women request cesareans is the fear of labor pain, in a country where a minority of women are given any form of pain relief during labor. Drawing upon ethnographic fieldwork and in-depth interviews with 26 postpartum women and 8 providers at a Shanghai district hospital in June and July of 2015, this article elucidates how perceptions of labor pain and the environment of pain relief constructs the cesarean on maternal request. In particular, many women feared labor pain and, in a context without effective pharmacological pain relief or social support during labor, they came to view cesarean sections as a way to negotiate their labor pain. In some cases, women would request cesarean sections during labor as an expression of their pain and a call for a response to their suffering. However, physicians, under recent state policy, deny such requests, particularly as they do not view pain as a reasonable indication for a cesarean birth. This disconnect leads to a mismatch in goals for the experience of birth. To reduce unnecessary C-sections, policy makers should instead address the lack of pain relief during childbirth and develop other means of improving the childbirth experience that may relieve maternal anxiety, such as allowing family members to support the laboring woman and integrating a midwifery model for low-risk births within China's maternal-services system.

Adverse Events at Baseline in a Chinese General Hospital: A Pilot Study of the Global Trigger Tool

OBJECTIVE

To investigate adverse events (AEs) at baseline in a Chinese general hospital using the Institute for Healthcare Improvement (IHI) Global Trigger Tool (GTT) and discuss the feasibility of this tool to detect AEs in China.

METHODS

A total of 10 inpatient records from the hospital were sampled randomly half a month in 2014. The records were reviewed to identify AEs according to the second edition of the IHI GTT for measuring AEs. Triggers and AEs were analyzed using Microsoft Excel 2007. Statistical analyses were performed using IBM SPSS software, version 19.0.

RESULTS

A review of 240 patient records identified 51.0% (26/51) triggers in the worksheet, and 33.3% (17/51) were associated with AEs. A total of 70 AEs were identified in 54 patients, including 65.7% (46/70) category E AEs, which represent temporary harm requiring intervention, and 34.3% (24/70) category F AEs, which represent temporary harm requiring initial or prolonged hospitalization. The average rate of AEs per 1000 patient-days was 32.1 ± 20.9. The average rate of AEs per 100 admissions was 29.2 ± 16.1. The average rate of admissions with an AE was 22.5% ± 13.9%. The most significant characteristic of patients with AEs was longer hospital stay.

CONCLUSIONS

More than one fifth of adult inpatients in the current study experienced at least one AE resulting in temporary harm, most commonly caused by surgical operations and medication. With some modifications, the IHI GTT is a feasible and effective tool for detecting the overall status of AEs in a Chinese hospital.