Using a birth ball to reduce pain perception in the latent phase of labour: a randomised controlled trial

BACKGROUND

Admission in the latent phase of labour is associated with higher rates of obstetric intervention. Women are frequently admitted due to pain. This study aimed to determine whether using a birth ball at home in the latent phase of labour reduces pain perception on admission.

METHOD

A prospective, pragmatic randomised controlled trial of 294 low risk pregnant women aged 18 and over planning a hospital birth. An animated educational video was offered at 36 weeks' gestation along with a birth ball. The primary outcome was pain on a Visual Analogue Scale on admission in labour. Participants who experienced a spontaneous labour were invited to respond to an online questionnaire 6 weeks' postpartum.

RESULTS

There were no differences in the mean pain scores; (6.3 versus 6.5; 90%CI -0.72 to 0.37 p = 0.6) or mean cervical dilatation on admission (4.7 cm versus 5.0 cm; 95% CI -1.1 to 0.5 p = 0.58). More Intervention participants were admitted in active labour (63.6% versus 55.7%; p = 0.28) and experienced an unassisted vaginal birth (70.3% v. 65.8%; p = 0.07) with fewer intrapartum caesarean sections (7.5% v. 17.9%; p = 0.07) although the trial was not powered to detect these differences in secondary outcomes. Most participants found the birth ball helpful (89.2%) and would use it in a future labour (92.5%).

CONCLUSION

Using the birth ball at home in the latent phase is a safe and acceptable strategy for labouring women to manage their labour, potentially postpone admission and reduce caesarean section. Further research is warranted.

Women's experience of early labour in a free-standing birth centre: Midwifing embodied labour

ISSUE

Women who present at hospital labour wards in early labour must often meet measurable diagnostic criteria before admission.

BACKGROUND

Early labour is a phase of neurohormonal, emotional, and physical changes that are often not measurable. When admission to birthplace is based on results of diagnostic procedures, women's embodied knowledge may be disregarded.

AIM

To describe the early labour experience of women with spontaneous onset of labour in a free-standing birth centre, as well as midwifery care when women arrived in labour.

METHODOLOGY

An ethnographic study was conducted in 2015 in a free-standing birth centre after receiving ethics approval. The findings for this article were drawn from a secondary analysis of the data, which included interview data with women and detailed field notes of midwives' activities related to early labour.

FINDINGS

The women in this study were instrumental in the decision-making process to stay at the birth centre. Observational data showed that vaginal exams were rarely conducted when women arrived at the birth centre and were not a deciding factor in admission.

DISCUSSION

The women and midwives co-constructed early labour based on the lived experience of women and the meaning that this experience held for both.

CONCLUSION

Given the growing concern about the need for respectful maternity care, this study provides examples of good practice in listening to women, as well as an illustration of the consequences of not doing so.

Symptoms of onset of labour and early labour: A scoping review

BACKGROUND

Early labour care often insufficiently addresses the individual needs of pregnant women leading to great dissatisfaction. In-depth knowledge about symptoms of onset of labour and early labour is necessary to develop women-centred interventions.

QUESTION OR AIM

To provide an overview on the current evidence about pregnant women's symptoms of onset of labour and early labour.

METHODS

We conducted a scoping review in the five databases PubMed, Web of Science, CINHAL Complete, PsychInfo and MIDIRS in May 2021 and August 2022 using a sensitive search strategy. A total of 2861 titles and abstracts and 290 full texts were screened independently by two researchers using Covidence. For this article, data was extracted from 91 articles and summarised descriptively and narratively.

FINDINGS

The most frequently mentioned symptoms were 'Contractions, labour pain' (n = 78, 85.7 %), 'Details about the contractions' (n = 51 articles, 56.0 %), 'Positive and negative emotions' (n = 50, 54.9 %) and 'Fear and worries' (n = 48 articles, 52.7 %). Details about the contractions ranged from a slight pulling to unbearable pain and the emotional condition varied from joy to great fear, showing an extraordinary diversity of symptoms highlighting the very individual character of early labour.

DISCUSSION

A comprehensive picture of varying and contradicting symptoms of onset of labour and early labour was drawn. Different experiences indicate different needs. This knowledge builds a good basis to develop women-centred approaches to improve early labour care.

CONCLUSION

Further research is necessary to design individualised early labour interventions and evaluate their effectiveness.

Early labour experience questionnaire: Translation and cultural adaptation into German

PROBLEM

Evidence on early labour care suggests that women's needs are not adequately met.

BACKGROUND

Women's perceptions of early labour management impact on their overall birth experience. Valid measurement tools are needed for evaluation and improvement of early labour care.

AIM

Translation and cultural adaptation of the Early Labour Experience Questionnaire for use in a German context.

METHODS

Translation and adaptation followed internationally recognised guidelines. The process comprised for- and backward translation, an expert panel review using a three-round modified Delphi process and cognitive interviews with representatives of the target group using paraphrasing and retrospective probing. The interviews were conducted online, video-recorded and transcribed. Based on the results of the interviews the pilot version of the questionnaire was compiled.

FINDINGS

Nine experts, including a representative of the target group, participated in the Delphi process. Twelve cognitive interviews were conducted. Most of the translation and adaptation issues needing clarification related to differences in the organisation of maternity care, the term early labour and the translation of the single word expressions for women's affective state in early labour. Few problems emerged during cognitive interviews and related to conceptual understanding, reference points, instructions, and response categories. The pilot version of the German Early Labour Experience Questionnaire (G-ELEQ) comprises a total of 25 items.

CONCLUSION

With the G-ELEQ a tool for measuring women's early labour experience in the German context with good face and content validity is available. Psychometric testing is now needed to assess the instrument's validity and reliability.

Let's talk early labour: The L-TEL randomised controlled trial

BACKGROUND

Women without complications have lower obstetric intervention if they remain at home in early labour but many women report dissatisfaction in doing this. Using self-efficacy theory as an underpinning framework, a web-based intervention was co-created with women who had previously used maternity services. The intervention provides early labour advice, alongside the videoed, real experiences of women.

METHOD

The pragmatic, randomised control trial aimed to evaluate the impact of the web-based intervention on women's self-reported experiences of early labour. Low-risk, nulliparous, pregnant women (140) were randomised. The intervention group (69) received the web-based intervention antenatally to use at their own convenience and the control group (71) received usual care. Data were collected at 7-28 days postnatally using an online version of the Early Labour Experience Questionnaire (ELEQ). The primary outcome was the ELEQ score. Secondary, clinical outcomes such as labour onset, augmentation and mode of birth were collected from the existing hospital system.

RESULTS

There were no statistically significant differences in the ELEQ scores between trial arms. Women in the intervention group were significantly more likely to progress spontaneously in labour without the need for labour augmentation (39.1 %) compared to the control group (21.1 %) (OR 2.41, CI 95 %; 1.14-5.11).

CONCLUSION

Although the L-TEL Trial found no statistically significant differences in the primary outcome, the innovative intervention to support women during latent phase labour was positively received by women. Web-based resources are a cost effective, user-friendly and accessible way to provide women with education. A larger trial is needed to detect differences in clinical outcomes.

Timing of hospital admission at first childbirth: A prospective cohort study

BACKGROUND AND AIMS

It is difficult for women in labor to determine when best to present for hospital admission, particularly at first childbirth. While it is often recommended that women labor at home until their contractions have become regular and ≤ 5-minutes apart, little research has investigated the utility of this recommendation. This study investigated the relationship between timing of hospital admission, in terms of whether women's labor contractions had become regular and ≤ 5-minutes apart before admission, and labor progress.

METHODS

This was a cohort study of 1,656 primiparous women aged 18-35 years with singleton pregnancies who began labor spontaneously at home and delivered at 52 hospitals in Pennsylvania, USA. Women who were admitted before their contractions had become regular and ≤ 5-minutes apart (early admits) were compared to those who were admitted after (later admits). Multivariable logistic regression models were used to assess associations between timing of hospital admission and active labor status on admission (cervical dilation 6-10 cm), oxytocin augmentation, epidural analgesia and cesarean birth.

RESULTS

Nearly two-thirds of the participants (65.3%) were later admits. These women had labored for a longer time period before admission (median, interquartile range [IQR] 5 hours (3-12 hours)) than the early admits (median, (IQR) 2 hours (1-8 hours), p < 0.001); were more likely to be in active labor on admission (adjusted OR [aOR] 3.78, 95% CI 2.47-5.81); and were less likely to experience labor augmentation with oxytocin (aOR 0.44, 95% CI 0.35-0.55); epidural analgesia (aOR 0.52, 95% CI 0.38-0.72); and cesarean birth (aOR 0.66, 95% CI 0.50-0.88).

CONCLUSIONS

Among primiparous women, those who labor at home until their contractions have become regular and ≤ 5-minutes apart are more likely to be in active labor on hospital admission and less likely to experience oxytocin augmentation, epidural analgesia and cesarean birth.

Exploring pain characteristics in nulliparous women; A precursor to developing support for women in the latent phase of labour

BACKGROUND

Admission to hospital in the latent phase of labour is associated with a cascade of unnecessary intervention. Women who seek early hospital admission may have heightened fear and anxiety in relation to pain routed in their pre-pregnancy experiences.

OBJECTIVE

To determine the prevalence of pain catastrophising in a healthy non-pregnant population and explore previous pain experiences and fear of childbirth as characteristics that might predict pain catastrophising.

DESIGN

Prospective observational study across two higher education institutions in Scotland and England using a semi-structured survey administered through Bristol Online Surveys. Four validated questionnaires were used to identify the prevalence of pain catastrophising and fear of childbirth in nulliparous women of reproductive age.

RESULTS

The survey was completed by 122 women undertaking an undergraduate degree and aged between 18 and 23 years. A high prevalence of pain catastrophising was found: a cut-off score of 20 and above = 47.5% (58/122 participants), a cut-off score of 30 and above = 21.3% (26/122). Fear of pain (β = 0.14, t = 4.21, p <0 .001) and pain-related anxiety (β = 0.40, t = 11.39, p <0 .001) were significant predictors of pain catastrophisation. However, there was no correlation between fear of childbirth and pain catastrophisation.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

It is reasonable to hypothesise that the pain catastrophising scale may be a good tool to predict those women likely to require additional support in the latent phase of labour; however further work is needed to explore this with a group of pregnant women.

A survey exploring women's use of mobile apps in labour in the United Kingdom

OBJECTIVE

To examine women's use of mobile apps in labour in the United Kingdom.

DESIGN

Cross-sectional online survey. Descriptive analysis on women's reported use of apps whilst in labour, using multiple choice questions to explore frequency of app use and reasons and experiences of using apps. Thematic analysis of a free text question explored experiences and opinions regarding app use in labour.

SETTING

Social media. Two groups from Facebook.com and one group from Babycentre.co.uk PARTICIPANTS: A total of 749 women, surveyed over a one month period.

MEASUREMENTS

Demographics of women; characteristics of women's labours and birth; access to smartphones and app; rates of app use in labour and reasons for use; experiences of app use in labour.

FINDINGS

A total of 851 women responded, of which 749 were eligible. 431 (57.5%) reporting using an app in labour. No associations were found between age, ethnicity, education or mode of delivery and app use. Women who used an app were significantly more likely to have gone into labour spontaneously, and those who delivered between 40- 40+6 weeks gestation were significantly more likely to use an app. The majority of apps were used to monitor contractions, and most women found the apps useful and would recommend the apps they used. There was no association between number of labour ward attendances and app use, however women who used an app were significantly more likely to be admitted in more advanced labour. Qualitative comments found apps were viewed both as barriers and facilitators to the labour experience.

KEY CONCLUSIONS

A large number of women are using apps in labour, with potential benefits. There is no consensus from women on the experience of app use. The use of technology should not replace an individual assessment on a laboring women however. Although national bodies support the use of apps in maternity, there is currently insufficient evidence and regulation to support the safety and efficacy of these recommendations.

IMPLICATIONS FOR PRACTICE

Those working in maternity services should be aware many women are using apps in labour, and can consider this information as part of their assessment. Further work is needed to explore what women want from an app in labour, and to investigate whether app use can benefit a woman's experience of labour and improve outcomes.

Variations in outcomes for women admitted to hospital in early versus active labour: an observational study

Background

There is no available evidence for the prevalence of early labour admission to hospital or its association with rates of intervention and clinical outcomes in Australia. The objectives of this study were to: estimate the prevalence of early labour admission in one hospital in Australia; compare rates of clinical intervention, length of hospital stay and clinical outcomes for women admitted in early (< 4 cm cervical dilatation) or active (≥4 cm) labour; and determine the impact of recent recommendations to define early labour as < 5 cm on the findings.

Methods

We conducted a retrospective cohort study using medical record data from a random sample of 1223 women from live singleton births recorded between July 2013 and December 2015. Analyses included women who had spontaneous onset of labour at ≥37 weeks gestation whilst not a hospital inpatient, who had not scheduled a caesarean section before labour onset or delivered prior to hospital admission. Associations between timing of hospital admission in labour and clinical intervention, outcomes and hospital stay were assessed using logistic regression.

Results

Between 32.4% (< 4 cm) and 52.9% (< 5 cm) of eligible women (N = 697) were admitted to hospital in early labour. After adjustment for potential confounders, women admitted in early labour (< 4 cm) were more likely to have their labour augmented by oxytocin (AOR = 3.57, 95% CI 2.39–5.34), an epidural (AOR = 2.27, 95% CI 1.51–3.41), a caesarean birth (AOR = 3.50, 95% CI 2.10–5.83), more vaginal examinations (AOR = 1.73, 95% CI = 1.53–1.95), and their baby admitted to special care nursery (AOR = 1.54, 95% CI = 1.01–2.35). Defining early labour as < 5 cm cervical dilatation produced additional significant associations with artificial rupture of membranes (AOR = 1.41, 95% CI = 1.02–1.95), assisted vaginal birth (AOR = 1.96, 95% CI = 1.12–3.41) neonatal resuscitation (AOR = 1.73, 95% CI = 1.01–2.99) and longer maternal hospital stay (AOR = 1.21, 95% CI = 1.04–1.40).

Conclusions

Findings provide preliminary evidence that a notable proportion of labouring women are admitted in early labour and are more likely to experience several medical procedures, neonatal resuscitation and admission to special care nursery, and longer hospital stay.

Women's unmet needs in early labour: Qualitative analysis of free-text survey responses in the M@NGO trial of caseload midwifery

OBJECTIVE

to analyse women's experiences of early labour care in caseload midwifery in Australia.

DESIGN

this study sits within a multi-site randomised controlled trial of caseload midwifery versus standard care. Participant surveys were conducted at 6-weeks and 6-months after birth. Free-text responses about experiences of care were subject to critical thematic analysis in NVivo 11 software.

SETTING

two urban Australian hospitals in different states.

PARTICIPANTS

women 18 years and over, with a singleton pregnancy, less than 24 weeks' pregnant, not planning a caesarean section or already booked with a care provider; were eligible to participate in the trial.

INTERVENTIONS

participants were randomised to caseload midwifery or standard care for antenatal, labour and birth and postpartum care.

MEASUREMENTS AND FINDINGS

The 6-week survey response rate was 58% (n = 1,019). The survey included five open questions about women's experiences of pregnancy, labour and birth, and postnatal care. Nine-hundred and one respondents (88%) provided free text comments which were coded to generate 10 categories. The category of early labour contained data from 84 individual participants (caseload care n = 44; standard care n = 40). Descriptive themes were: (1) needing permission; (2) doing the 'wrong' thing; and (3) being dismissed. Analytic themes were: (1) Seeking: women wanting to be "close to those who know what's going on"; and (2) Shielding: midwives defending resources and normal birth.

KEY CONCLUSIONS

Regardless of model of care, early labour care was primarily described in negative terms. This could be attributed to reporting bias, because women who were neutral about early labour care may not comment. Nevertheless, the findings demonstrate a gap in knowledge about early labour care in caseload midwifery models.

IMPLICATIONS FOR PRACTICE

Maternity services that offer caseload midwifery are ideally placed to evaluate how early labour home visiting impacts women's experiences of early labour.

'The calm before the storm': A qualitative study of fathers' experiences of early labour

BACKGROUND

Early labour care presents a challenge for maternity services and is a cause of dissatisfaction for women planning birth in an obstetric or midwifery unit who may feel unsupported or unwelcome at their planned place of birth. Little is known about the perspectives of men who support their partner during early labour.

METHODS

Opportunity sample offathers (n=12) in the UK who had been present during their partner's labour in the previous twelve months. Semi-structured interviews were audio-recorded and transcribed before thematic analysis.

RESULTS

Fathers learned about the stages of labour during antenatal education and felt well prepared for early labour but found their knowledge difficult to apply, and relied on their partners to decide when to travel to the planned place of birth. Early labour was described as the 'calm before the storm' during which they carried out practical tasks or rested to ensure they could fulfil their role when labour progressed. However, men frequently felt 'like a spare part' during the later stages of labour.

DISCUSSION

The study has implications for antenatal educators, midwives and others supporting couples during pregnancy and labour. It supports reconsideration of how information about labour progress can be most usefully conveyed to couples. Professionals could acknowledge the value of supportive tasks carried out by fathers that might otherwise be experienced as doing 'nothing'. Further research should recruit more diverse samples of men and same-sex couples. Dyadic data collection methods may be of value.

Women's labour experiences and quality of care in relation to a prolonged latent phase of labour

AIM

To describe primiparous and multiparous women's labour experiences and their perception of quality of intrapartum care, in relation to background characteristics and length of latent phase of labour prior to admittance to labour ward.

DESIGN

A cross-sectional study.

SETTING

A middle-sized hospital in a rural county in western part of Sweden.

PARTICIPANTS

Primiparous and multiparous women, both low-risk and risk, with a spontaneous onset of labour after gestational week 37+0 were included. In total, n = 1193 women were invited, and n = 757 responded the questionnaire, n = 342 primiparous and n = 415 multiparous women.

METHODS

The Intrapartal-specific Quality from Patient Perspective (QPP-I), with responses on perceived reality and subjective importance, was used for data collection. QPP-I covers ten factors of quality of care. Background characteristics, length of latent phase of labour, global items about labour experience and items regarding feelings during labour and birth were included. Data were analysed with descriptive and analytic statistics.

FINDINGS

All factors in QPP-I were rated higher for subjective importance than perceived reality, except for information about selfcare, for both primi- and multiparous women. Labour experience, perceived reality of quality of care, and feelings were related to length of the latent phase of labour. Primiparous women with a prolonged latent phase (>18 h) had significantly lower scores regarding six out of ten QPP-I factors (PR); Information procedures, Information self-care, Commitment (midwives), Commitment (enrolled nurses), Midwives present, and Partner/ significant others. They scored lower on Experience birth as normal and Safe during labour and birth. The felt less proud and felt more ignored by professionals. Multiparous women with a prolonged latent phase of labour scored significantly lower on one QPP-I factor, Commitment (midwives). They also scored lower on Control over the situation and felt less safe during labour and birth.

KEY CONCLUSION

Women's perception of quality of intrapartum care, the birth experience and feelings are related to length of the latent phase of labour. Women perceive quality of intrapartum care as being lower than its subjective importance.

IMPLICATIONS FOR PRACTICE

A prolonged latent phase of labour can be regarded as a risk factor for a more negative birthing experience.

The ontology of early labour (and the difficulties of talking about it): Using interview methods to investigate uncertain and gendered concepts

This article presents reflections on the process of collecting interview data about fathers’ experiences of ‘early labour’. Early labour is the first phase of labour, defined in textbooks by regular contractions and cervical dilation of up to 4 cm. Women are typically encouraged to stay at home during early labour and only travel to hospital when they are in ‘active labour’. Maternity services (and other providers of antenatal education) devote a great deal of attention to educating parents-to-be about the phases of labour and about how to recognise the ‘right time’ to travel to hospital but ‘early’ admission remains a problem. Prompted by suggestions in the existing literature that male partners may influence when women seek admission, my research set out to explore fathers’ understanding and experiences of early labour. However, interviewing fathers about early labour was challenging and, in this article, I will argue that this was due to a particular configuration of practical, epistemological and ontological issues. I argue that early labour is a slippery and uncertain concept beyond the clinical context and that Mol’s ‘multiple ontologies’ provides productive tools for reflecting on the difficulty of asking about early labour, keeping early labour in focus during the interviews, and finding early labour in the data. However, the gendered nature of reproductive social research requires additional analysis to understand the gender dynamics at work when asking about reproductive research objects of multiple or uncertain ontologies.

A qualitative study of midwives' perceptions on using video-calling in early labor

BACKGROUND

Decisions made in early labor influence the outcomes of childbirth for women and infants. Telephone assessment during labor, the current norm in many settings, has been found to be a source of dissatisfaction for women and can present challenges for midwives. The aim of this qualitative study was to explore midwives' views on the potential of video-calling as a method for assessing women in early labor.

METHODS

A series of 8 midwife focus groups (n = 45) and interviews (n = 4) in the Midlands region of England and the mid-South and Northeast regions of the United States were completed. Audio recordings were transcribed verbatim and coded using content analysis. Coding diagrams were used to help develop major themes in the data.

RESULTS

Midwives were generally positive about the potential of video-calling in early labor and using visual cues to make more accurate assessments and to enhance trust. Some midwives expressed concerns about privacy, both for themselves and for women, and issues of accessibility. They suggested strategies for implementation and further research, such as the need for a private space in birth facilities and training for both staff and service users.

CONCLUSIONS

Video-calling was seen as a viable option for assessment of women in early labor with some particular challenges related to implementation. This research focused on midwives' views; the views of women and their families should also be considered. There is a lack of evidence on the clinical and cost effectiveness of video-calling in maternity care and further research is warranted.

Decision Making about Hospital Arrival among Low-Risk Nulliparous Women after Spontaneous Labor Onset at Home

INTRODUCTION

Postponing hospital admission until the active phase of labor is a recommended strategy to safely reduce the incidence of primary cesarean births. Success of this strategy depends on women's decisions about when to transfer from home to the hospital, a process that is largely absent from research about childbirth. This study aimed to determine the decision-making criteria used by women about when to go to the hospital after the self-identification of labor onset at home.

METHODS

A qualitative study was conducted at an academic medical center with a sample of 21 nulliparous women who went into spontaneous labor at home and had term, singleton, and vertex-presentation births. The purposive sample consisted of women who decided to stay at home or go to the hospital in early labor. Birth narratives from in-depth interviews conducted in the postpartum period using a semistructured interview guide were subjected to content analysis. The verbatim transcriptions of the interviews were coded and categorized into a set of decision criteria.

RESULTS

Criteria used by women in deciding to go to the hospital or stay at home in early labor included the degree of certainty with the self-identification of labor onset, ability to cope with labor pain, influence of social network members, health care provider advice, and concerns about travel to the hospital. Perception of childbirth risk and the need for reassurance about the normalcy of symptoms and fetal well-being also influenced women's decisions.

DISCUSSION

Women use a common set of criteria in deciding when to arrive at the hospital during labor. Antenatal education and telephone triage interventions that incorporate the considerations of women deciding to seek or delay hospital admission in childbirth may facilitate health seeking in more advanced labor. Symptom recognition education about early labor onset and progression could reduce decisional uncertainty.

In labor or in limbo? The experiences of women undergoing induction of labor in hospital: Findings of a qualitative study

BACKGROUND

Induction of labor currently accounts for around 25% of all births in high-resource countries, yet despite much research into medical aspects, little is known about how women experience this process. This study aimed to explore in depth the induction experience of primiparous women.

METHODS

A qualitative study was undertaken, using a sample of 21 first-time mothers from a maternity unit in the south of England. Semi-structured interviews were conducted in women's homes between 3 and 6 weeks postnatally. Data were recorded, transcribed, and analyzed thematically.

RESULTS

Women awaiting induction on the prenatal ward appeared to occupy a liminal state between pregnancy and labor. Differences were noted between women's and midwives' notions of what constituted "being in labor" and the ward lacked the flexibility to provide individualized care for women in early labor. Unexpected delays in the induction process were common and were a source of anxiety, as was separation from partners at night. Women were not always clear about their plan of care, which added to their anxiety.

CONCLUSIONS

Conceptualizing induction as a liminal state may enhance understanding of women's feelings and promote a more woman-centered approach to care. Thorough preparation for induction, including an explanation of possible delays is fundamental to enabling women to form realistic expectations. Care providers need to consider whether women undergoing induction are receiving adequate support, analgesia, and comfort aids conducive to the promotion of physiological labor and the reduction of anxiety.

Experiences of early labour management from perspectives of women, labour companions and health professionals: A systematic review of qualitative evidence

OBJECTIVES

to examine evidence of women's, labour companions' and health professionals' experiences of management of early labour to consider how this could be enhanced to better reflect women's needs.

DESIGN

a systematic review of qualitative evidence.

SETTING AND PARTICIPANTS

women in early labour with term, low risk singleton pregnancies, not booked for a planned caesarean birth or post-dates induction of labour, their labour companions, and health professionals responsible for early labour care (e.g. midwives, nurse-midwives, obstetricians, family doctors). Studies from high and middle income country settings were considered.

FINDINGS

21 publications were included from the UK, Ireland, Scandinavia, USA, Italy and New Zealand. Key findings included the impact of communication with health professionals (most usually midwives) on women's decision making; women wanting to be listened to by sympathetic midwives who could reassure that symptoms and signs of early labour were 'normal' and offer clear advice on what to do. Antenatal preparation which included realistic information on what to expect when labour commenced was important and appreciated by women and labour companions. Views of the optimal place for women to remain and allow early labour to progress differed and the perceived benefit of support and help offered by labour companions varied. Some were supportive and helped women to relax, while others were anxious and encouraged women to seek early admission to the planned place of birth. Web-based sources of information are increasingly used by women, with mixed views of the value of information accessed.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

women, labour companions and health professionals find early labour difficult to manage well, with women unsure of how decisions about admission to their planned place of birth are taken. It is unclear why women are effectively left to manage this aspect of their labour with minimal guidance or support. Tailoring management to meet individual needs, with provision of effective communication could reassure women and facilitate timely admission from perspectives of women, their companions, midwives and other health professionals. Information on labour onset and progress, and approaches to pain management, should be shared with women's labour companions to enable them to feel more confident to better support women. Further research is needed of the impact of different models of care and increasing use of web-based information on women's approaches to self-management when labour commences. PROSPERO 2014 CRD 42014009745.

Assessment and support during early labour for improving birth outcomes

BACKGROUND

The progress of labour in the early or latent phase is usually slow and may include painful uterine contractions. Women may feel distressed and lose their confidence during this phase. Support and assessment interventions have been assessed in two previous Cochrane Reviews. This review updates and replaces these two reviews, which have become out of date.

OBJECTIVES

To investigate the effectiveness of assessment and support interventions for women during early labour.In order to measure the effectiveness of the interventions, we compared the duration of labour, the rate of obstetrical interventions, and the rate of other maternal or neonatal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (31 October 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials of any assessment or support intervention in the latent phase of labour. We planned to include cluster-randomised trials if they were eligible. We did not include quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We resolved any disagreement by discussion or by involving a third assessor. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

We included five trials with a total of 10,421 pregnant women in this review update. The trials were conducted in the UK, Canada and America. The trials compared interventions in early labour versus usual care. We examined three comparisons: early labour assessment versus immediate admission to hospital; home visits by midwives versus usual care (telephone triage); and one-to-one structured midwifery care versus usual care. These trials were at moderate- risk of bias mainly because blinding women and staff to these interventions is not generally feasible. For important outcomes we assessed evidence using GRADE; we downgraded evidence for study design limitations, imprecision, and where we carried out meta-analysis, for inconsistency.One trial with 209 women compared early labour assessment with direct admission to hospital. Duration of labour from the point of hospital admission was reduced for women in the assessment group (mean difference (MD) -5.20 hours, 95% confidence interval (CI) -7.06 to -3.34; 209 women, low-quality evidence). There were no clear differences between groups for the number of women undergoing caesarean section or instrumental vaginal birth (risk ratio (RR) 0.72, 95% CI 0.30 to 1.72, very low quality evidence; and, RR 0.86, 95% CI 0.58 to 1.26, very low quality evidence, respectively). Serious maternal morbidity was not reported. Women in the early assessment group were slightly less likely to have epidural anaesthesia (RR 0.87, 95% CI 0.78 to 0.98, low-quality evidence), and considerably less likely to have oxytocin for labour augmentation (RR 0.57, 95% CI 0.37 to 0.86) and this group also had increased satisfaction with their care compared with women in the immediate admission group (MD 16.00, 95% CI 7.53 to 24.47). No babies were born before admission to hospital and only one infant had a low Apgar score at five minutes after the birth (very low quality evidence). Admission to neonatal special care was not reported.Three studies examined home assessment and midwifery support versus telephone triage. One trial reported the duration of labour; home visits did not appear to have any clear impact compared with usual care (MD 0.29 hours, 95% CI -0.14 to 0.72; 1 trial, 3474 women, low-quality evidence). There was no clear difference for the rate of caesarean section (RR 1.05, 95% CI 0.95 to 1.17; 3 trials, 5170 women; I² = 0%; moderate-quality evidence) or the rate of instrumental vaginal birth (average RR 0.95, 95% CI 0.79 to 1.15; 2 trials, 4933 women; I² = 69%; low-quality evidence). One trial reported birth before arrival at hospital or unplanned home birth; there was no clear difference between the groups (RR 1.33, 95% CI 0.30 to 5.95; 1 trial, 3474 women). No clear differences were identified for serious maternal morbidity (RR 0.93, 95% CI 0.61 to 1.42; 1 trial, 3474 women; low-quality evidence), or use of epidural (average RR 0.95, 95% CI 0.87 to 1.05; 3 trials, 5168 women; I² = 60%; low-quality evidence). There were no clear differences for neonatal admission to special care (average RR 0.84, 95% CI 0.50 to 1.42; 3 trials, 5170 infants; I² = 71%; very low quality evidence), or for Apgar score less than seven at five minutes after birth (RR 1.19, 95% CI 0.71 to 1.99; 3 trials, 5170 infants; I² = 0%; low-quality evidence).One study, with 5002 women, examined one-to-one structured care in early labour versus usual care. Length of labour was not reported. There were no clear differences between groups for the rate of caesarean section (RR 0.93, 95% CI 0.84 to 1.02; 4996 women, high-quality evidence), or for instrumental vaginal birth (RR 0.94, 95% CI 0.82 to 1.08; 4996 women, high-quality evidence). No clear differences between groups were reported for serious maternal morbidity (RR 1.13, 95% CI 0.84 to 1.52; 4996 women, moderate-quality evidence). Use of epidural was similar in the two groups (RR 1.00, 95% CI 0.99 to 1.01; 4996 women, high-quality evidence). For infant outcomes, there were no clear differences between groups (admission to neonatal intensive care unit: RR 0.98, 95% CI 0.80 to 1.21; 4989 infants, high-quality evidence; Apgar score less than seven at five minutes: RR 1.07, 95% CI 0.64 to 1.79; 4989 infants, moderate-quality evidence).

AUTHORS' CONCLUSIONS

Assessment and support in early labour does not have a clear impact on rate of caesarean section or instrumental vaginal birth, or whether the baby was born before arrival at hospital or in an unplanned home birth. However, evidence suggested that interventions may have an impact on reducing the use of epidural anaesthesia, labour augmentation and on increasing maternal satisfaction with giving birth. Evidence about the effectiveness of early labour assessment versus immediate admission was very limited and more research is needed in this area.

Being in a safe and thus secure place, the core of early labour: A secondary analysis in a Swedish context

BACKGROUND

Early labour is the very first phase of the labour process and is considered to be a period of time when no professional attendance is needed. However there is a high frequency of women who seek care at the delivery wards during this phase. When a woman is admitted to the delivery ward, one role for midwives is to determine whether the woman is in established labour or not. If the woman is assessed as being in early labour she will probably then be advised to return home. This recommendation is made due to past research that found that the longer a woman is in hospital the higher the risk for complications for her and her child. Women have described how this situation leaves them in a vulnerable situation where their preferences are not always met and where they are not always included in the decision-making process.

AIM

The aim of this study was to generate a theory based on where a woman chooses to be during the early labour process and to increase our understanding about how experiences can differ from place to place.

METHODS

The method was a secondary analysis with grounded theory. The data used in the analysis was from two qualitative interview studies and 37 transcripts.

CONCLUSION

The findings revealed a substantive theory that women needed to be in a safe and thus secure place during early labour. This theory also describes the interplay between how women ascribed their meaning of childbirth as either a natural live event or a medical one, how this influenced where they wanted to be during early labour, and how that chosen place influenced their experiences of labour and birth.

"Is it realistic?" the portrayal of pregnancy and childbirth in the media

BACKGROUND

Considerable debate surrounds the influence media have on first-time pregnant women. Much of the academic literature discusses the influence of (reality) television, which often portrays birth as risky, dramatic and painful and there is evidence that this has a negative effect on childbirth in society, through the increasing anticipation of negative outcomes. It is suggested that women seek out such programmes to help understand what could happen during the birth because there is a cultural void. However the impact that has on normal birth has not been explored.

METHODS

A scoping review relating to the representation of childbirth in the mass media, particularly on television.

RESULTS

Three key themes emerged: (a) medicalisation of childbirth; (b) women using media to learn about childbirth; and (c) birth as a missing everyday life event.

CONCLUSION

Media appear to influence how women engage with childbirth. The dramatic television portrayal of birth may perpetuate the medicalisation of childbirth, and last, but not least, portrayals of normal birth are often missing in the popular media. Hence midwives need to engage with television producers to improve the representation of midwifery and maternity in the media.

Development and psychometric properties of the Early Labour Experience Questionnaire (ELEQ)

OBJECTIVE

to describe the development and psychometric properties of the Early Labour Experiences Questionnaire (ELEQ).

DESIGN

randomized controlled trial.

SETTING

hospitals serving obstetric populations in metropolitan and suburban Vancouver, British Columbia, Canada.

PARTICIPANTS

423 healthy nulliparous women in labour at term with uncomplicated pregnancies.

INTERVENTION

women were randomized to telephone support (n=241) or home visit (n=182) study groups and completed the ELEQ during the postpartum phase of their hospital stay.

MEASUREMENT

the ELEQ contains 26 self-report items, rated on a 5-point scale, that measure women's affective experience of early labour (14 items), perceptions of nursing care (12 items), whether they would recommend this type of early labour care to a friend (1 item), and whether they believed they went to the hospital at the right time (1 item). An exploratory factor analysis was conducted to determine whether the items grouped together into subscales. The structural reliability of the extracted subscales and total scores were evaluated using a number of coefficients. To test criterion validity, we compared ELEQ item, subscale and total scores between the study groups.

FINDINGS

item and total scores showed significant variability. Factor analysis yielded three subscales: Emotional Well-Being, Emotional Distress and Perceptions of Nursing Care. The subscale and total scores showed good internal consistency and item homogeneity, and were interrelated in the expected direction. Items evidenced strong associations with the subscale and total scores. Comparisons between study groups offered some support for criterion validity.

KEY CONCLUSIONS

pending further validation, the ELEQ can contribute to the assessment of women's experiences with different aspects of maternity care, evaluation of the quality of maternity care, and improvement of maternity services.

Women's perspectives of the stages and phases of labour

BACKGROUND

within childbirth there is a common and widely known explanation of labour and birth which describes and defines the birth process as stages and phases. The aim of this research was to determine whether the discourse of labour as stages and phases resonated with women who had experienced spontaneous labour and birth.

METHOD

a critical feminist standpoint methodology was used to explore the perspectives of 18 New Zealand women through in-depth, one to one, interviews.

FINDINGS

the participants did not talk about their labour as occurring in stages or phases and often considered this description to be an abstract concept. The current descriptions of labour onset and progression did not appear to resonate with these women or provide sufficient clarity for them to understand how far they had progressed in their labour. For women who had previously laboured there was the ability to make comparisons with their previous experiences and therefore experiential knowledge was privileged over other forms of knowledge. Despite this the discourse of measurement of cervical dilatation was dominant and considered as an authoritative means of determining labour and labour progress.

CONCLUSION AND IMPLICATION FOR PRACTICE

women considered labour to be a continuous process. If women are to be able to make sense of their experience of labour, the maternity sector needs to explore and determine descriptions of labour which resonate more fully with the woman's experience of labour and birth.

Early labour services: changes, triggers, monitoring and evaluation

OBJECTIVES

to identify the changes to early labour services, their triggers and monitoring.

DESIGN AND SETTING

a mixed methods approach in two stages, firstly a postal questionnaire survey of Heads of Midwifery (HoM) services in NHS Trusts in England (cover sheet to each HoM and questionnaire for each unit in their jurisdiction) and, secondly, semi-structured telephone interviews with a purposive sample of senior midwives. The interviews sought further information about reasons for change; the impact of changes and explored the unit's particular innovations. PARTICIPANTS AND RESPONSE RATE: 145 (89%) NHS Trusts provided data (cover sheet and/or questionnaire); responses were received from all areas and types of unit. Seventeen HoMs or designated senior midwives were interviewed.

FINDINGS

83 of 170 units (49%) had made changes to early labour service provision during the past 5 years, including home assessment; the introduction of triage units and telephone assessment tools. Changes were more likely in high volume units and in consultant units with midwifery-led care areas. Further changes were planned by 93/178 (25%) units. Triggers for changes to early labour services comprised local or unit-based factors, including Category X (non-labour) admissions, response to service users and research evidence. The impact of Category X admissions on workload contributed to the triggers for change. Fifty-six (31%) could provide a confirmed figure or estimate for category X admissions. Experiences of introducing change included issues related to engagement of the workforce and the contribution of clinical leadership. Thirty-eight (48%) units did not routinely monitor use of early labour services. Overall monitoring of services was not significantly more likely in units that had made changes. Audit activity was reported more frequently in units that had made changes to their early labour services.

CONCLUSIONS

early labour services had undergone significant changes following a range of triggers but the extent of change was not reflected in monitoring and evaluation activity.

IMPLICATIONS FOR PRACTICE

Changes to service provision should be accompanied by monitoring and evaluation. Changes to services require utilisation of appropriate change management strategies.

Women's preferences for aspects of labor management: results from a discrete choice experiment

BACKGROUND

The latent phase of labor can vary greatly in duration, and many women are uncertain about when to contact the maternity unit. The aim of this study was to elicit and value women's preferences for some aspects of labor management.

METHODS

A questionnaire was sent to 1,251 women who had recently given birth to their first child at one of 14 maternity units in Scotland. Discrete choice questions were used to measure women's preferences for five attributes of care: number of visits (assessments) before admission to the labor ward, time spent on the labor ward before delivery, mobility during labor, pain relief required, and mode of delivery. Responses were analyzed for the sample as a whole and for subgroups defined by recent experiences of labor.

RESULTS

A total of 730 (58.4%) questionnaires were returned and analyzed. Women expressed a preference for fewer visits before admission, shorter times on the labor ward before delivery, mobility during labor, normal vaginal deliveries, and moderate forms of pain relief (Entonox and opiates). Subgroup analysis suggests that women's preferences for pain relief are influenced by their recent labor experience. The elicited preference values provide a means for estimating the tradeoffs women are willing to make between attributes of labor management.

CONCLUSIONS

Women appear to dislike being turned away from the labor ward before admission for delivery. Extra visits before admission only appear to be a price worth paying if they result in reductions in the duration of time spent on the labor ward, reductions in the chance of being immobilized in hospital during labor, or a lower chance of requiring an instrumental or operative delivery.