Antenatal and intrapartum interventions for reducing caesarean section, promoting vaginal birth, and reducing fear of childbirth: An overview of systematic reviews

Lateral recumbent position versus kneeling prone position combined with unprotected perineal delivery in natural childbirth: implication for clinical care

BACKGROUND

Posture management significantly influences the natural childbirth process and the maternal experience. The aim of this study is to analyze the effects of the lateral recumbent position versus the kneeling prone position combined with unprotected perineal delivery in natural childbirth, providing evidence-based support for clinical maternal care and posture management.

METHODS

This research constitutes a retrospective cohort investigation, encompassing a period from January 2022 to December 2023, and focusing on women in labor who experienced childbirth at our medical facility. The study meticulously assessed and compared the characteristics and clinical outcomes of those who adopted the lateral recumbent position with those who utilized the kneeling prone position during the process of natural childbirth.

RESULTS

A total of 168 women in labor were included, 86 women in labor underwent lateral recumbent position and 82 women in labor underwent kneeling prone position for natural childbirth. There were no statistical differences in first, second, third and total stage of labor between lateral recumbent position group and kneeling prone position group were found (all P > 0.05). Visual Analogue Scale (VAS) and Self-Rating Anxiety Scale (SAS) score after labor in lateral recumbent position group were statistically lower than that of kneeling prone position group(all P < 0.05). The lateral recumbent position reduced the likelihood of episiotomy and perineal edema, the severity of perineal lacerations compared with kneeling prone position for natural childbirth (all P < 0.05).

CONCLUSION

Lateral recumbent position in natural childbirth offers the advantage of reducing perineal trauma, alleviating maternal pain and anxiety, and may be therefore deemed worthy of utilization in clinical maternal care.

Evaluating the implementation of person-centred care and simulation-based learning in a midwifery education programme in the Democratic Republic of Congo: a study protocol

BACKGROUND

Investing in midwives educated according to international standards is crucial for achieving Sustainable Development Goals in maternal and newborn health. Applying a person-centred care approach and using simulation-based learning to improve the learning experience for midwifery students may enhance the quality of childbirth care. This protocol describes a study evaluating the implementation of person-centred approach and simulation-based learning in childbirth as part of a midwifery education programme at the Evangelical University in Africa, DRC.

METHODS

The research will be exploratory and guided by an implementation research framework. Ethical approval has been obtained. Facilitators working at the programme's five clinical practice sites will be trained in: 1) Introducing person-centred childbirth care using a training programme called'Mutual Meetings'; and 2) integrating simulation-based learning, specifically by using the three courses: Essential Care of Labor, Bleeding after Birth, and Vacuum Extraction. Data will include interviews with midwifery students, facilitators and clinical preceptors, and maternal and neonatal outcomes from birth registers.

DISCUSSION

By integrating a validated and culturally adapted person-centred care training programme and simulation-based learning into a midwifery education programme and clinical practice sites, the findings from the study anticipate an improvement in the quality of childbirth care. Training facilitators in these methodologies aim to effectively mitigate maternal and neonatal adverse outcomes. The findings are expected to provide valuable recommendations for governments, policymakers, and healthcare providers in the DRC and beyond, contributing to significant improvements in midwifery education and aligning with global health priorities, including the Sustainable Development Goals.

TRIAL REGISTRATION

The study was registered retrospectively with the ISRCTN registry on the 23rd of February 2024. The registration number is: ISRCTN10049855.

The Consequences of A History of Violence on Women's Pregnancy and Childbirth in the Nordic Countries: A Scoping Review

Violence against women (VAW) is a global challenge also in the childbearing period. Despite high gender equality, there is a high prevalence of VAW in the Nordic countries. This scoping review aims to explore predictors for and consequences of a history of violence on women's pregnancy and childbirth in the Nordic countries, including women's experience of the impact of violence and the interventions used to detect, address consequences, and prevent further violence. The framework by Arksey and O'Malley was followed, and English, Finnish, Icelandic, Norwegian, Danish, and Swedish literature was included. The population was women aged ≥18 residing in the Nordic countries during the perinatal period. Eight databases were searched: MEDLINE, CINAHL, PubMed, PsycINFO, Web of Science, ASSIA, Social Services-, and Sociological abstracts. There was no limitation of the search time frame. The initial screening resulted in 1,104 records, and after removing duplicates, 452 remained. Finally, 61 papers met the inclusion criteria. The results covering the past 32 years indicated that childbearing women with a history of violence are at greater risk of common complaints and hospitalization during pregnancy, fear of childbirth, Cesarean section, breastfeeding difficulties, and physical and mental health problems. While extensive research was found on the associations between a history of and current violence and outcomes related to pregnancy, there was a lack of intervention studies and studies from Finland. Efforts must be made to scientifically test the methods used to reduce and treat the adverse effects of a history of violence and prevent further violence.

[Effect of the Spinning Babies Program on Birth Outcomes and Satisfaction during Labor: A Non-Randomized Controlled Trial]

PURPOSE

This study evaluated the effects of the Spinning Babies program applied during labor on birth outcomes and satisfaction among pregnant women.

METHODS

This non-equivalent control group, non-synchronized post-test only design study included 42 participants (22 in the experimental group and 20 in the control group). The Spinning Babies program was conducted four times in the experimental group during the first and second stages of delivery for 50 min per session. The program comprised performing pelvic circles on a birth ball, followed by wide squatting and adopting of open knee-chest and side-lying positions.

RESULTS

Compared with those in the control group, pregnant women in the experimental group had a significantly shorter labor time (t = -6.64, p < .001), a higher success rate for normal vaginal delivery (χ² = 4.86, p = .043), improved Apgar scores of newborns (z² = -2.18, p = .029), differences in neonatal oxygen therapy use (χ² = 4.86, p = .043), and improved birth satisfaction (t = 11.99, p < .001).

CONCLUSION

The Spinning Babies program improves the birth environment by increasing the normal vaginal delivery success rate, as well as pregnant women's birth satisfaction, and promotes neonatal health.

Fast-and-frugal decision tree for the rapid critical appraisal of systematic reviews

Conducting high-quality overviews of reviews (OoR) is time-consuming. Because the quality of systematic reviews (SRs) varies, it is necessary to critically appraise SRs when conducting an OoR. A well-established appraisal tool is A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2, which takes about 15-32 min per application. To save time, we developed two fast-and-frugal decision trees (FFTs) for assessing the methodological quality of SR for OoR either during the full-text screening stage (Screening FFT) or to the resulting pool of SRs (Rapid Appraisal FFT). To build a data set for developing the FFT, we identified published AMSTAR 2 appraisals. Overall confidence ratings of the AMSTAR 2 were used as a criterion and the 16 items as cues. One thousand five hundred and nineteen appraisals were obtained from 24 publications and divided into training and test data sets. The resulting Screening FFT consists of three items and correctly identifies all non-critically low-quality SRs (sensitivity of 100%), but has a positive predictive value of 59%. The three-item Rapid Appraisal FFT correctly identifies 80% of the high-quality SRs and correctly identifies 97% of the low-quality SRs, resulting in an accuracy of 95%. The FFTs require about 10% of the 16 AMSTAR 2 items. The Screening FFT may be applied during full-text screening to exclude SRs with critically low quality. The Rapid Appraisal FFT may be applied to the final SR pool to identify SR that might be of high methodological quality.

Synchronization of a Virtual Reality Scenario to Uterine Contractions for Labor Pain Management: Development Study and Randomized Controlled Trial

Background: Labor is described as one of the most painful events women can experience through their lives, and labor pain shows unique features and rhythmic fluctuations. Purpose: The present study aims to evaluate virtual reality (VR) analgesic interventions for active labor with biofeedback-based VR technologies synchronized to uterine activity. Materials and Methods: We developed a VR system modeled on uterine contractions by connecting it to cardiotocographic equipment. We conducted a randomized controlled trial on a sample of 74 cases and 80 controls during active labor. Results: Results of the study showed a significant reduction of pain scores compared with both preintervention scores and to control group scores; a significant reduction of anxiety levels both compared with preintervention assessment and to control group and significant reduction in fear of labor experience compared with controls. Conclusion: VR may be considered as an effective nonpharmacological analgesic technique for the treatment of pain and anxiety and fear of childbirth experience during labor. The developed system could improve personalization of care, modulating the multisensory stimulation tailored to labor progression. Further studies are needed to compare the synchronized VR system to uterine activity and unsynchronized VR interventions.

Effectiveness of mind-body interventions in labour pain management during normal delivery: A systematic review and meta-analysis

BACKGROUND

Labour pain is a common experience among women and poses risks to both the mother and neonate. Mind-body interventions have demonstrated effectiveness in diverse contexts, but their effectiveness in labour pain management remains controversial.

OBJECTIVE

To identify the effects of each category of mind-body interventions on labour pain management, particularly pain intensity; the use of pharmacological pain relief medications; and the consequent outcomes, including the rate of caesarean section, duration of labour, and fear of childbirth.

DESIGN

Systematic review and meta-analysis.

METHODS

A systematic search for related articles was conducted in 10 databases. Randomised controlled trials focusing on the effectiveness of mind-body interventions in labour pain management were included. Two researchers independently conducted methodological quality assessments, data extraction and grading the evidence. Meta-analyses were conducted when studies measured the same outcomes. Standardised mean differences were calculated for continuous variables, whilst risk ratios were calculated for dichotomous variables. All analyses were performed using RevMan version 5.3.

RESULTS

A total of 25 studies from 24 trials were included, and six categories of mind-body interventions, namely hypnosis, mindfulness, breathing skills, muscle relaxation techniques, guided imagery, and therapeutic touch, were identified. Specifically, hypnosis and mindfulness might be effective in relieving labour pain intensity, with large effect sizes (SMD: -1.45, 95 % confidence interval [CI] -2.34, -0.55, I2 = 91 %; SMD: -1.22, 95 % CI -2.07, -0.37, I2 = 93 %, respectively), but could not reduce the use of epidural analgesia. Mindfulness, in particular, yielded statistically significant reductions in the rate of caesarean section, with a small effect size (RR: 0.46, 95 % CI 0.21, 0.97, I2 = 49 %), and in fear of childbirth, with a medium effect size (SMD: -0.63, 95 % CI -1.09, -0.17, I2 = 65 %). Additionally, all categories of mind-body interventions were associated with a significantly decreased duration of labour compared with the control conditions.

CONCLUSIONS

Mind-body interventions may have potential benefits in terms of decreasing labour pain intensity, the rate of caesarean section, the duration of labour, and fear of childbirth, with small-to-large effect sizes. Particularly, hypnosis and mindfulness exhibited significant positive effects in terms of relieving labour pain intensity, with large effect sizes. These interventions could serve as complementary or alternative methods for labour pain management in clinical practice. Nevertheless, further rigorous randomised controlled trials are warranted to confirm our results.

REGISTRATION

CRD42024498600 (PROSPERO, January 15, 2024).

The iSEARCH randomised controlled trial protocol: a pragmatic Australian phase III clinical trial of intrapartum sildenafil citrate to improve outcomes potentially related to intrapartum hypoxia

INTRODUCTION

We showed in a phase II randomised controlled trial (RCT) that oral sildenafil citrate in term labour halved operative birth for fetal distress. We outline the protocol for a phase III RCT (can intrapartum SildEnafil safely Avert the Risks of Contraction-induced Hypoxia? (iSEARCH)) of 3200 women in Australia to assess if sildenafil citrate reduces adverse perinatal outcomes related to intrapartum hypoxia.

METHODS AND ANALYSIS

iSEARCH will enrol 3200 Australian women in term labour to determine whether up to three 50 mg oral doses of sildenafil citrate versus placebo reduce the relative risk of a primary composite end point of 10 perinatal outcomes potentially related to intrapartum hypoxia by 35% (from 7% to 4.55%). Secondary aims are to evaluate reductions in the relative risk of emergency caesarean section or instrumental vaginal birth for fetal distress by 25% (from 20% to 15%) and in healthcare costs. To detect a 35% reduction in the primary outcome for an alpha of 0.05 and power of 80% with 10% dropout in each arm requires 3200 women (1600 in each arm). This sample size will also yield >90% power to detect a 25% reduction for the secondary outcome of any operative birth (caesarean section or instrumental vaginal birth) for fetal distress.

ETHICS AND DISSEMINATION

Ethical approval for the iSEARCH RCT was granted by the Hunter New England Human Research Ethics Committee (ref no: 2020/ETH02791). Results will be disseminated through websites, peer-reviewed publications, scientific meetings and social media, news outlets, television and radio.

TRIAL REGISTRATION NUMBER

ACTRN12621000231842.

Effects of multiple protection model in the operating room on physiological stress and risk events in patients undergoing coronary artery stent implantation

OBJECTIVE

To analyze the impact of multiple protection model in the operating room on patients' physiological stress and risk events after coronary artery stent implantation (CASI).

METHODS

During October 2021 to October 2022, 150 patients with coronary heart disease (CHD) were picked as the research subjects, all of whom underwent CASI. The clinical data were retrospectively analyzed, and the patients were divided into two groups according to different nursing methods, with 75 cases in each group. Patients in the intervention group received multiple protection model intervention in the operating room, and the patients in the control group adopted conventional care model. The patient satisfaction with nursing, postoperative recovery, psychological stress scores, physiological stress indicators, and adverse cardiac risk events were recorded.

RESULTS

Patients in the intervention group had much higher percentage of the patient satisfaction with nursing than those in the control group (P < 0.05). The time to get out of bed and hospital stay was significantly shorter and the 6-min walking distance was markedly longer in the intervention group than the control (P < 0.05). The Hamilton Anxiety (HAMA) scale and Hamilton Depression (HAMD) scale score of patients in two groups were sharply decreased after the intervention (P < 0.05), which were strongly lower in the intervention group than the control (P < 0.001). After the intervention, the heart rate, cortisol and epinephrine of patients were all sensibly elevated in two groups (P < 0.05), which were all memorably lower in the intervention group than the control (P < 0.001). The incidence of adverse cardiac risk events in the intervention group was 5.33%, which was dramatically lower than 16.00% in the control group (P < 0.05).

CONCLUSION

The application of multiple protection model in the operating room on patients undergoing coronary stent implantation promoted postoperative recovery, reduced patients' psychological and physiological stress, maintained blood pressure and other vital signs, reduced the incidence of adverse cardiac risk events, and improved the patient satisfaction with nursing.

Couples' perceptions and experience of smartphone-assisted CenteringPregnancy model in southeast of China: a dyadic analysis of qualitative study

OBJECTIVES

The objectives of this study are to describe couples' experiences and perceived barriers to participation in the CenteringPregnancy model in southeast of China and to understand whether smartphones could play a potential role in this model.

DESIGN

This study employed a descriptive phenomenological qualitative study using semistructured dyadic interviews with women and their partners. The interviews were audiotaped, transcribed verbatim and subjected to thematic analysis.

SETTING

This study was conducted in two pilot prenatal clinics in southern China.

PARTICIPANTS

A purposive sample of 13 couples who underwent smartphone-assisted CenteringPregnancy were recruited. Data were collected until saturation through semistructured dyadic interviews between December 2022 and March 2023.

RESULTS

The study yielded four primary themes: (1) motivation for participation, (2) acceptance of CenteringPregnancy, (3) barriers and suggestions and (4) support for smartphone use of CenteringPregnancy.

CONCLUSIONS

CenteringPregnancy was well received by couples. Couples can access additional medical care and engage in intensive social interactions assisted by smartphones. However, certain objective challenges need to be acknowledged, including inadequate activity space, high demand for knowledge by couples and inflexible time for employed partners. Moreover, the risk that smartphones can lead to false expectations among couples needs to be noted.

How the Mode of Delivery Is Influenced by Patient's Opinions and Risk-Informed Consent in Women with a History of Caesarean Section? Is Vaginal Delivery a Real Option after Caesarean Section?

Background/Objectives: In recent years, there has been a noticeable increase in the rates of caesarean section (CS), being one of the most commonly performed surgical procedures. For the following pregnancy, the previous CS represents the backbone of the risks and complications, such as uterine scar formation, uterine rupture, massive bleeding, and serious negative outcomes for both the mother and child. Our study followed patients with a history of CS from the birth planning prenatal check-up to delivery. Methods: We reviewed the records of 125 pregnant women with previous CS who presented in the third trimester for a prenatal check-up and completed our questionnaire from March 2021 to April 2022 in the Clinic of Obstetrics and Gynecology, Diakoneo Diak Klinikum Schwäbisch Hall, Germany. Results: Before the prenatal check-up, 74 patients (59.2%) preferred vaginal delivery (VD), while 51 (40.8%) preferred CS. After discussing birth planning with the obstetrician, 72 women (57.6%) decided upon VD, while 53 (42.4%) preferred CS. Ultimately, 78 (62.4%) of women gave birth through CS (either planned or by medical necessity) and 47 (37.6%) gave birth vaginally (either natural or per vacuum extraction). Conclusions: VD for patients with CS in their medical history is a real option. The patient must be well informed about the risks and benefits of the medical situation and should be empowered and supported on their chosen mode of delivery, which should be respected.

Caesarean sections before and during the COVID-19 pandemic in western Sydney, Australia

BACKGROUND

To determine the changes in emergency and elective caesarean section (CS) rates since the COVID-19 pandemic, identify the groups most affected, and examine changes in the factors associated with CS rates, and reasons for CS.

METHODS

We conducted a retrospective cohort study using routinely collected data of 22,346 births from before the pandemic (January 2018-February 2020) and 18,597 births during the pandemic (March 2020-December 2021). Data were analysed using multinominal logistic regression.

RESULTS

The CS rate increased by 4.1% (from 30.1% to 34.2%), reflecting increases of 2.3% in emergency CS (from 11.5% to 13.8%) and 1.7% in elective CS (from 18.7% to 20.4%). Large groups with notable increases were women who were nulliparous (7.2% increase), from South Asia (6.0%), obese (5.2%) and giving birth at a small hospital (6.1%). Compared to pre-pandemic, the relative risk of an emergency CS versus a vaginal delivery increased 1.36 times (adjusted relative risk ratio (aRRR) = 1.36; 95% CI = 1.27, 1.45) and the risk of having an elective CS increased 1.11 times (aRRR = 1.11; 95% CI = 1.04, 1.20). Factors associated with both emergency and elective CS were age, region of birth, reproductive history, body mass index, hypertension, diabetes, mode of antenatal care and hospital. Socio-Economic Indexes for Areas and antenatal care were only associated with elective CS. Baby gender was only associated with emergency CS. Preterm gestation at delivery was associated with reduced emergency but increased elective CS. Foetal compromise was the most common indication for emergency CS (43.2%) and increased the most (8.0%). Previous CS was the most common indication for elective CS (61.5%) and reduced the most (1.9%).

CONCLUSIONS

Both emergency and elective CS rates increased significantly during the pandemic, with the former increasing at a higher rate. The persistent upward trend of CS rates, exacerbated by increasing proportions of nulliparous women undergoing CSs, is concerning.

The effectiveness of mindfulness-based interventions on self-efficacy and fear of childbirth in pregnant women: A systematic review and meta-analyses

BACKGROUND

Mindfulness-based interventions are a relatively new and potentially useful psychological approach in prenatal care. This study aimed to determine the effect of mindfulness-based programs on pregnant women's fear of childbirth FOC and self-efficacy.

METHODS

The systematic search of PubMed, Scopus, Web of Science, Cochrane Library, Google Scholar, SID, and Magiran databases began on 11 November 2021 and ended on 17 December 2021 to obtain studies published in English and Persian without date constraints. Another search was conducted in March 2023. The Cochrane handbook tool was used to evaluate selected studies and their risk of bias.

RESULTS

From a total of 316 records obtained, after removing duplicate items, 16 full texts were evaluated for eligibility; and finally, 10 studies were included in the study and meta-analysis. Based on the results of meta-analyses, mindfulness-based exercises may improve childbirth self-efficacy (SMD = 1.34, 95 % CI: 0.39 to 2.30; P < 0.00001; 5 studies, 304 women; low-certainty evidence) and probably reduce the level of FOC (SMD = -0.71, 95 % CI: -1.14 to -0.27; P = 0.001; 5 studies, 424 women; moderate-certainty evidence) in the intervention group compared to the control group.

LIMITATIONS

Different duration of interventions across studies, different gestational ages at the time of enrollment, and large heterogeneity in the meta-analysis of results were the limitations of this study.

CONCLUSION

Mindfulness-based interventions probably reduce FOC and may promote self-efficacy. More randomized controlled trials with stronger designs and adequate power samples are required to verify the effectiveness of mindfulness-based interventions, especially on self-efficacy in pregnant women.

PROSPERO ID

CRD42021294056.

Antenatal Fear of Childbirth as a Risk Factor for a Bad Childbirth Experience

Giving birth is one of the most impressive experiences in life. However, many pregnant women suffer from fear of childbirth (FOC) and experience labour in very different ways, depending on their personality, previous life experiences, pregnancy, and birth circumstances. The aim of this study was to analyse how fear of childbirth affects the childbirth experience and to assess the related consequences. For this, a descriptive cross-sectional study was carried out in a sample of 414 women between 1 July 2021 and 30 June 2022. The Birth Anticipation Scale (BAS) was used to measure fear of childbirth and the Childbirth Experience Questionnaire (CEQ-E) was applied to measure satisfaction with the childbirth experience. Fear of childbirth negatively and significantly predicted the childbirth experience. In addition, women who were more fearful of childbirth were found to have worse obstetric outcomes and a higher likelihood of having a caesarean delivery (p = 0.008 C. I 95%). Fear behaved as a risk factor for the birth experience, so the greater the fear, the higher the risk of having a worse birth experience (OR 1.1). Encouraging active listening and support strategies may increase pregnant women's confidence, thus decreasing their fear of the process and improving their childbirth experience.

The effect of organizational belonging and profession on clinicians' attitudes toward supporting vaginal birth and interprofessional teamwork-a cross-sectional study

INTRODUCTION

The aim of this study was to investigate the effect of organizational belonging and profession on clinicians' attitudes toward supporting vaginal birth and interprofessional teamwork in Swedish maternity care.

MATERIAL AND METHODS

The study used a cross-sectional design, with a web-based survey sent to midwives, physicians and nurse assistants at five labor wards in Sweden. The survey consisted of two validated scales: the Swedish version of the Labor Culture Survey (S-LCS), measuring attitudes toward supporting vaginal birth, and the Assessment of Collaborative Environments (ACE-15), measuring attitudes toward interprofessional teamwork. Two-way ANOVA was conducted to assess the main effect of and interaction effect between organizational belonging and profession for the different subscales of the S-LCS and the ACE-15, together with Tukey's honest significant difference post-hoc analysis and partial eta squared to determine effect size. The relation between the subscales was assessed using the Pearson's correlation analysis.

RESULTS

A total of 539 midwives, physicians and nurse assistants completed the survey. Organizational belonging significantly influenced attitudes toward supporting vaginal birth and interprofessional teamwork, with the largest effect for Positive team culture (F = 38.88, effect size = 0.25, p < 0.001). The effect of profession was strongest for the subscale Best practices (F = 59.43, effect size = 0.20, p < 0.001), with midwives being more supportive of strategies proposed to support vaginal birth than physicians and nurse assistants. A significant interaction effect was found for four of the subscales of the S-LCS, with the strongest effect for items reflecting the Unpredictability of vaginal birth (F = 4.49, effect size = 0.07, p < 0.001). Labor ward culture (unit microculture) specifically related to supporting vaginal birth was strongly correlated to interprofessional teamwork (r = 0.598, p < 0.001).

CONCLUSIONS

In the current study, both organizational belonging and profession influenced attitudes toward supporting vaginal birth and interprofessional teamwork. Positive team culture was positively correlated to an organizational culture supportive of vaginal birth. Interventions to support vaginal births should include efforts to strengthen teamwork between professions, as well as considering women's values, preferences and informed choices.

Factors associated with cesarean birth in nulliparous women: A multicenter prospective cohort study

BACKGROUND

There is widespread concern around the rising rates of cesarean births (CBs), especially among first-time mothers, despite evidence suggesting increased morbidities after birth by cesarean. There are uncertainties around factors associated with rising rates of CBs among first-time mothers in Ireland, and insight into these is essential for understanding the rising trend in CBs. Therefore, this study aimed to identify the factors associated with CBs in nulliparous women.

METHODS

A prospective cohort study was conducted in three maternity hospitals in the Republic of Ireland between 2012 and 2017. Data were collected from 3047 nulliparous women using self-administered surveys antenatally and at 3 months postpartum and from consenting women's hospital records (n = 2755) and analyzed using the Poisson regression to assess associations between demographic and clinical factors and the main outcome measures, planned and unplanned CBs.

RESULTS

Common risk factors for planned and unplanned CBs were being aged ≥40 years, being in private care, multiple pregnancy, and fetus in breech or other malpresentations. An unplanned CB occurred for 22.43% (n = 377/1681) of women who did not have induction of labor (IOL) or who had IOL with no epidural, but the risk was about twice as high for women who had IOL and epidural.

CONCLUSIONS

Findings confirm multifactorial reasons for CB and the challenge of reversing the increasing CB rate if maternal age, overweight/obesity, infertility treatment, multiple pregnancy, and preexisting hypertension in Ireland continue to increase. There is a need to address prelabor interventions, especially IOL combined with epidural analgesia with respect to unplanned CB.

Prediction of odds for emergency cesarean section: A secondary analysis of the CHILD term birth cohort study

INTRODUCTION

Previously developed cesarean section (CS) and emergency CS prediction tools use antenatal and intrapartum risk factors. We aimed to develop a predictive model for the risk of emergency CS before the onset of labour utilizing antenatal obstetric and non-obstetric factors.

METHODS

We completed a secondary analysis of data collected from the CHILD Cohort Study. The analysis was limited to term (≥37 weeks), singleton pregnant women with cephalic presentation. The sample was divided into a training and validation dataset. The emergency CS prediction model was developed in the training dataset and the performance accuracy was assessed by the area under the receiver operating characteristic curve(AUC) of the receiver operating characteristic analysis (ROC). Our final model was subsequently evaluated in the validation dataset.

RESULTS

The participant sample consisted of 2,836 pregnant women. Mean age of participants was 32 years, mean BMI of 25.4 kg/m2 and 39% were nulliparous. 14% had emergency CS delivery. Each year of increasing maternal age increased the odds of emergency CS by 6% (adjusted Odds Ratio (aOR 1.06,1.02-1.08). Likewise, there was a 4% increase odds of emergency CS for each unit increase in BMI (aOR 1.04,1.02-1.06). In contrast, increase in maternal height has a negative association with emergency CS. The final emergency CS delivery predictive model included six variables (hypertensive disorders of pregnancy, antenatal depression, previous vaginal delivery, age, height, BMI). The AUC for our final prediction model was 0.74 (0.72-0.77) in the training set with a similar AUC in the validation dataset (0.77; 0.71-0.82).

CONCLUSION

The developed and validated emergency CS delivery prediction model can be used in counselling prospective parents around their CS risk and healthcare resource planning. Further validation of the tool is suggested.

'Labour Hopscotch': Women's evaluation of using the steps during labor

INTRODUCTION

Concerns have been expressed globally about the decline in rates of physiological birth and rising intervention rates during labor and birth. The 'Labour Hopscotch' Framework, a visual depiction of steps required to remain active during labor was implemented in a large tertiary maternity hospital in Ireland. The aim of this study was to evaluate the steps of the Labour Hopscotch women found most useful, examine the use of non-pharmacological and pharmacological methods of pain relief used during labor and finally to investigate the labor and birth outcomes of women who used 'Labour Hopscotch' during labor.

METHODS

A descriptive cross-sectional study was conducted using a study specific questionnaire.

RESULTS

A total of 809 women completed the questionnaire. The Labour Hopscotch Framework was positively evaluated. Mobilizing, the birthing ball, birthing stool, and water therapy were found to be the most useful steps. Primiparous women were more likely to use non-pharmacological methods of pain relief. Pharmacological methods used by women were entonox (67.5%), pethidine (8%) and epidural analgesia (38.5%). Primiparous women were more likely to have epidural analgesia than multiparous women (p<0.00001). Women that attended either private (p=0.004) or public-led obstetric (p=0.005) antenatal care were more likely to have epidural analgesia in labor. Women attending the community midwives were least likely to receive epidural analgesia during labor. The rates of spontaneous vaginal birth, assisted birth and cesarean section, were 77.1%, 14% and 8.7%, respectively.

CONCLUSIONS

Our study findings contribute to the increasing national and international evidence that initiatives such as Labour Hopscotch can promote and advocate for women to be active and mobile during labor to support physiological birth.

Effects of Positive Psychological Nursing Combined with Free Posture on the Prognosis of Primipara with Singleton Spontaneous Delivery

Objective

To explore the effects of positive psychological nursing combined with free posture on the prognosis of primipara with singleton spontaneous delivery.

Methods

106 cases of primipara with singleton spontaneous delivery who were admitted to the obstetrics department of our hospital from January 2017 to December 2019 were selected as the research subjects and they were divided into the observation group and control group according to the random number table method and maternal willingness, with 53 cases in each group. The control group received routine nursing, and the observation group was given positive psychological nursing combined with free posture on the basis of the control group. The stress degree during delivery (Hamilton anxiety scale (HAMA) and Hamilton depression scale (HAMD)), the time of first stage of labor, the time of second stage of labor, the time of third stage of labor, pain level during the active period of the first stage of labor, and delivery outcomes were observed and compared between the two groups.

Results

The degree of anxiety and depression during childbirth in the observation group was significantly lower than that in the control group (P < 0.05). The time of first stage of labor and the time of second stage of labor in the observation group were shorter than those in the control group (P < 0.05), and there was no significant difference in the time of the third stage of labor (P > 0.05). The pain degree in the active stage of the first stage of labor in the observation group was lower than that in the control group (P < 0.05). The pain degree in the active stage of the first stage of labor in the observation group was lower than that in the control group (P < 0.05).

Conclusion

Positive psychological nursing combined with free posture for primipara with singleton spontaneous delivery can shorten the stages of labor, reduce the pain, relieve psychological stress, and improve the delivery outcomes.

Labor induction in China: a nationwide survey

BACKGROUND

Overmedicalization in labor management and delivery, including labor induction, is an increasing global concern. But detailed epidemiological data on labor induction in China remains unclear.

METHODS

This was a cross-sectional study of data (2015-2016) from 96 hospitals in 24 (of 34) Chinese administrative divisions. Multivariable logistic regression analysis was used to assess the association between medical conditions and cesarean delivery among women undergoing induction. Linear regression analysis was performed to assess the association between the prelabor cesarean delivery and labor-induction rates in each hospital. The impacts of labor induction and prelabor cesarean delivery on maternal and neonatal outcomes were compared in low-risk women.

RESULTS

Among 73 901 eligible participants, 48.1% were nulliparous. The overall weighted rate of labor induction in China was 14.2% (95% CI, 11.1-17.2%), with 18.4% (95% CI, 14.5-22.3%) in nulliparas and 10.2% (95% CI, 7.7-12.8%) in multiparas. Regardless of the induction method, the overall vaginal delivery rate was 72.9% (95% CI, 68.6-77.3%) in nulliparas and 86.6% (95% CI, 79.7-93.5%) in multiparas. Hospitals with a higher rate of nonmedically indicated cesarean delivery had a lower labor-induction rate in nulliparas (β =  - 0.57%; 95% CI, - 0.92 to - 0.22%; P = 0.002). Compared with prelabor cesarean delivery, labor induction in low-risk women was not associated with adverse maternal and neonatal outcomes.

CONCLUSION

The 2015-2016 labor-induction rate in China was 18.4% in nulliparas and 10.2% in multiparas. The proportion of prelabor cesarean delivery may contribute to regional differences in the labor-induction rate. Compared with prelabor cesarean delivery, labor induction in low-risk women may not increase severe maternal and neonatal morbidity.

What would reduce caesarean section rates?—Views from pregnant women and clinicians in Ireland

Background

Caesarean section rates continue to rise in most parts of the world. While CS is a lifesaving procedure there is evidence that, beyond a certain threshold, CS rates may contribute to increased maternal and perinatal morbidity. This study aimed to elicit the views of pregnant women’s and clinicians’ on how CS rates might be reduced.

Methods

Pregnant women and their partners, and clinicians working with pregnant women in a maternity hospital in the Republic of Ireland of Ireland, were invited to participate in focus groups. Eligibility criteria included all women attending antenatal classes and clinicians working with pregnant women. A convenience sample was used and interviews were audio recorded, transcribed, and analysed using thematic analysis.

Results

Four focus group interviews were conducted with 30 clinicians and 15 pregnant women and two partners participated in three focus groups. A further two women were interviewed individually. Participants expressed a view that rising CS rates were impacted by a societal perception that CS had become a ‘normal mode of birth’. Suggestions for reducing CS rates were offered by clinicians and pregnant women and their partners.

Conclusions

Clinicians and pregnant women consider that CS rates can be reduced if a shared philosophy supporting normal birth is prioritised alongside adequate resourcing. Women and their partners also believe that enhanced communication with clinicians is central to reducing CS rates.

A new index for obstetrics safety and quality of care: integrating cesarean delivery rates with maternal and neonatal outcomes

BACKGROUND

Cesarean delivery rates have been used as obstetrical quality indicators. However, these approaches do not consider the accompanying maternal and neonatal morbidities. A challenge in the field of obstetrics has been to establish a valid outcomes quality measure that encompasses preexisting high-risk maternal factors and associated maternal and neonatal morbidities and is universally acceptable to all stakeholders, including patients, healthcare providers, payers, and governmental agencies.

OBJECTIVE

This study aimed to (1) establish a new single metric for obstetrical quality improvement among nulliparous patients with term singleton vertex-presenting fetus, integrating cesarean delivery rates adjusted for preexisting high-risk maternal factors with associated maternal and neonatal morbidities, and (2) determine whether obstetrician quality ranking by this new metric is different compared with the rating based on individual crude and/or risk-adjusted cesarean delivery rates. The single metric has been termed obstetrical safety and quality index.

STUDY DESIGN

This was a cross-sectional study of all nulliparous patients with term singleton vertex-presenting fetuses delivered by 12 randomly chosen obstetricians in a single institution. A review of all records was performed, including a review of maternal high-risk factors and maternal and neonatal outcomes. Maternal and neonatal medical records were reviewed to determine crude and adjusted cesarean delivery rates by obstetricians and quantify maternal and neonatal complications. We estimated the obstetrician-specific crude cesarean delivery rates and rates adjusted for obstetrician-specific maternal and neonatal complications from logistic regression models. From this model, we derived the obstetrical safety and quality index for each obstetrician. The final ranking based on the obstetrical safety and quality index was compared with the initial ranking by crude cesarean delivery rates. Maternal and neonatal morbidities were analyzed as ≥1 and ≥2 maternal and/or neonatal complications.

RESULTS

These 12 obstetricians delivered a total of 535 women; thus, 1070 (535 maternal and 535 neonatal) medical records were reviewed to determine crude and adjusted cesarean delivery rates by obstetricians and quantify maternal and neonatal complications. The ranking of crude cesarean delivery rates was not correlated (rho=0.05; 95% confidence interval, -0.54 to 0.60) to the final ranking based on the obstetrical safety and quality index. Of note, 8 of 12 obstetricians shifted their rank quartiles after adjustments for high-risk maternal conditions and maternal and neonatal outcomes. There was a strong correlation between the ranking based on ≥1 maternal and/or neonatal complication and ranking based on ≥2 maternal and/or neonatal complications (rho=0.63; 95% confidence interval, 0.08-0.88).

CONCLUSION

Ranking based on crude cesarean delivery rates varied significantly after considering high-risk maternal conditions and associated maternal and neonatal outcomes. Therefore, the obstetrical safety and quality index, a single metric, was developed to identify ways to improve clinician practice standards within an institution. Use of this novel quality measure may help to change initiatives geared toward patient safety, balancing cesarean delivery rates with optimal maternal and neonatal outcomes. This metric could be used to compare obstetrical quality not only among individual obstetricians but also among hospitals that practice obstetrics.

Childbirth fear, birth-related mindset and knowledge in non-pregnant women without birth experience

Background

Childbirth fear and interventions during childbirth might be related to the mindset and knowledge non-pregnant women have regarding childbirth. Non-pregnant women before their first birth experience may be particularly at risk for childbirth fear.

Methods

The present study examined the expressions and associations of birth-related mindset, knowledge, and fear among 316 young, non-pregnant women without birth experience. They participated in a cross-sectional online study and completed the Childbirth Fear Prior to Pregnancy, the Mindset and Birth Questionnaire, and a birth knowledge test.

Results

Most women (44%) had a natural mindset and low fear, 29% had a medical mindset and low fear, 8% natural mindset and higher fear, and 19% medical mindset and higher fear.

There were no differences in knowledge between the four groups. Some gaps in knowledge appeared concerning signs of beginning birth, and non-medical approaches to pain relief. From women with natural mindset and low childbirth fear, a higher percentage (13%) has already watched a birth, as compared to the other groups.

Natural mindset was associated with lower childbirth fear, whereas knowledge was independent from childbirth fear. Higher knowledge was low associated with natural mindset. Mindset and childbirth fear were independent from age and education degree.

Conclusions

Gynecologists, midwifes and other health professionals may develop an awareness for birth as a natural event in their non-pregnant patients, and take birth-related fear into account in their counseling, with focus on women’s self-efficacy and non-medical approaches to pain relief.

Tocophobia and Women's Desire for a Caesarean Section: a Systematic Review

Introduction:The rate of cesarean sections has been continuously increasing in most industrialized countries in recent years. It has been observed that the rate of cesarean sections has increased in the last thirty years and is now between 0.4 and 65%. A significant percentage of women, ranging from 1-20%, request a caesarean section without a medical indication. Aim:The aim of this study is to systematically review the available international literature concerning the phenomenon of tocophobia leading to woman`s desire for a caesarean section. Methods: The methodology followed, included an advanced search in various scientific databases and retrieval of the relevant quantitative studies. Results:We found a total of seven papers, all in English, which examined the correlation between tocophobia and women's desire for a caesarean section. Conclusions:One of the primary reasons behind women's desire to give birth through a caesarean delivery is the pathological fear associated with the labor process, known under the scientific term "tocophobia". According to the findings of this review, the prevalence of tocophobia ranged between 7-25% among primiparous women and 7.7-16.25% among multiparous ones. Approximately 7-18.6% of women with tocophobia asked for an elective cesarean section without any medical indication. Clinical treatment of tocophobia is required when the condition has a negative impact on the pregnant woman's quality of life and her bond with the embryo, as well as when it affects her decision regarding the method of childbirth.

Multilevel analysis to identify the factors associated with caesarean section in Bangladesh: evidence from a nationally representative survey

BACKGROUND

Caesarean delivery has a significant role in reducing maternal and child death. However, unnecessary utilization has adverse health effects. This study aimed to assess the prevalence and associated factors of caesarean delivery in Bangladesh.

METHODS

Data from the latest Bangladesh Multiple Indicator Cluster Survey (MICS, 2019) was used in this study. Since MICS data are hierarchical in nature, multilevel modelling was used.

RESULTS

The prevalence of caesarean section (CS) was 67.4% among Bangladeshi women. Multilevel analysis suggests the age of the women, household wealth status, utilization of antenatal care (ANC) , delivery at a health facility and division were significantly associated with CS. Women who delivered in a private health facility had the highest odds for CS (odds ratio [OR] 10.35 [95% confidence interval {CI} 8.55 to 12.54]). Women 30-34 y of age had a 36% higher likelihood of CS compared with women 15-19 y of age (OR 1.36 [95% CI 1.03 to 1.79]). The odds of CS positively increased with household wealth status. Women who had at least one ANC visit had a 1.7 times higher possibility of CS (OR 1.70 [95% CI 1.26 to 2.30]).

CONCLUSIONS

Policy guidelines on caesarean deliveries are urgently needed in Bangladesh to avoid unnecessary caesarean deliveries and protect mothers from the consequences.

Clinician's attitudes towards caesarean section: A cross-sectional survey in two tertiary level maternity units in Ireland

BACKGROUND

Although caesarean section (CS) is a life-saving intervention when medically indicated, the growth in CS rates is causing concern. In reducing unnecessary CS, it is important to understand clinicians' attitudes towards CS so that these might be understood contextually.

OBJECTIVE

To explore clinicians' attitudes towards CS in Ireland.

METHODS

A cross sectional survey involving maternity care professionals in two urban maternity hospitals in Ireland. Descriptive statistics were used to analyse the data. Ethical approval was granted by the Research Ethics Committees of the University and the two study sites.

FINDINGS

One hundred and fifty-two maternity care professionals responded to the survey. Most (97%) indicated that the CS rate in their unit was 'high', although 81% believed there was a shift in culture towards a lower threshold for performing CS. Most participants (85%) considered birth a natural process that should not be interfered with unless necessary and that elective CS is not the safest option for the mother (74%) or baby (71%), yet 45% believed that a woman should be able to have a CS if she wants a CS. Just over half the participants considered a previous 3rd or 4th degree tear an indication for an elective CS. Offering vaginal birth after a previous CS for fetal distress and failure to progress increased with clinical experience.

CONCLUSION

The findings of this survey can be considered contextually in addressing high CS rates and will be of wider relevance in understanding maternity care providers' beliefs about CS in general.

Interventions for fear of childbirth including tocophobia

BACKGROUND

Many women experience fear of childbirth (FOC). While fears about childbirth may be normal during pregnancy, some women experience high to severe FOC. At the extreme end of the fear spectrum is tocophobia, which is considered a specific condition that may cause distress, affect well-being during pregnancy and impede the transition to parenthood. Various interventions have been trialled, which support women to reduce and manage high to severe FOC, including tocophobia.

OBJECTIVES

To investigate the effectiveness of non-pharmacological interventions for reducing fear of childbirth (FOC) compared with standard maternity care in pregnant women with high to severe FOC, including tocophobia.

SEARCH METHODS

In July 2020, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies. We contacted researchers of trials which were registered and appeared to be ongoing.

SELECTION CRITERIA

We included randomised clinical trials which recruited pregnant women with high or severe FOC (as defined by the individual trial), for treatment intended to reduce FOC. Two review authors independently screened and selected titles and abstracts for inclusion. We excluded quasi-randomised and cross-over trials.

DATA COLLECTION AND ANALYSIS

We used standard methodological approaches as recommended by Cochrane. Two review authors independently extracted data and assessed the studies for risk of bias. A third review author checked the data analysis for accuracy. We used GRADE to assess the certainty of the evidence. The primary outcome was a reduction in FOC. Secondary outcomes were caesarean section, depression, birth preference for caesarean section or spontaneous vaginal delivery, and epidural use.

MAIN RESULTS

We included seven trials with a total of 1357 participants. The interventions included psychoeducation, cognitive behavioural therapy, group discussion, peer education and art therapy. We judged four studies as high or unclear risk of bias in terms of allocation concealment; we judged three studies as high risk in terms of incomplete outcome data; and in all studies, there was a high risk of bias due to lack of blinding. We downgraded the certainty of the evidence due to concerns about risk of bias, imprecision and inconsistency. None of the studies reported data about women's anxiety. Participating in non-pharmacological interventions may reduce levels of fear of childbirth, as measured by the Wijma Delivery Expectancy Questionnaire (W-DEQ), but the reduction may not be clinically meaningful (mean difference (MD) -7.08, 95% confidence interval (CI) -12.19 to -1.97; 7 studies, 828 women; low-certainty evidence). The W-DEQ tool is scored from 0 to 165 (higher score = greater fear). Non-pharmacological interventions probably reduce the number of women having a caesarean section (RR 0.70, 95% CI 0.55 to 0.89; 5 studies, 557 women; moderate-certainty evidence). There may be little to no difference between non-pharmacological interventions and usual care in depression scores measured with the Edinburgh Postnatal Depression Scale (EPDS) (MD 0.09, 95% CI -1.23 to 1.40; 2 studies, 399 women; low-certainty evidence). The EPDS tool is scored from 0 to 30 (higher score = greater depression). Non-pharmacological interventions probably lead to fewer women preferring a caesarean section (RR 0.37, 95% CI 0.15 to 0.89; 3 studies, 276 women; moderate-certainty evidence).  Non-pharmacological interventions may increase epidural use compared with usual care, but the 95% CI includes the possibility of a slight reduction in epidural use (RR 1.21, 95% CI 0.98 to 1.48; 2 studies, 380 women; low-certainty evidence).

AUTHORS' CONCLUSIONS

The effect of non-pharmacological interventions for women with high to severe fear of childbirth in terms of reducing fear is uncertain. Fear of childbirth, as measured by W-DEQ, may be reduced but it is not certain if this represents a meaningful clinical reduction of fear. There may be little or no difference in depression, but there may be a reduction in caesarean section delivery. Future trials should recruit adequate numbers of women and measure birth satisfaction and anxiety.

Association between migration status and caesarean section delivery based on a modified Robson classification in China

Background

China has one of the highest caesarean section (C-Section) rates in the world. In recent years, China has been experiencing a massive flow of migration due to rapid urbanization. In this study, we aimed to differentiate the rates of C-Section between migrants and residents, and explore any possible factors which may moderate the association between migrant status and C-Section rates.

Methods

We conducted a retrospective cohort study in Shanghai, China. All deliveries were classified using the modified Robson Classification. The association between women’s migrant status and C-Section rates was assessed using the Poisson regression of sandwich estimation, after adjusting for possible factors.

Results

Of the 40,621 women included in the study, 66.9% were residents and 33.1% were internal migrants. The rate of C-Section in migrants was lower than that of residents in all subjects (39.9 and 47.7%) and in group 1 subjects (based on the Robson Classification) using a modified Robson Classification. There was an association between migrant status and caesarean delivery on maternal request that was statistically significant (RR = 0.664, p < 0.001), but the association was weakened after adjusting for such factors as maternal age at delivery (aRR = 0.774, p = 0.02), ethnicity (aRR = 0.753, p < 0.001), health insurance (aRR = 0.755, p < 0.001), and occupation (aRR = 0.747, p = 0.004), but had no significant changes when adjusting for health conditions (aRR = 0.668, p = 0.001) and all considering variables (aRR = 0.697, p = 0.002). In group 1 subjects, the effect of migrant status on maternal requested intrapartum C-Section was also statistically significant (RR = 0.742, p = 0.004).

Conclusion

C-Section rates are lower among migrant women than residents, especially on maternal request. The medical practitioners should further reinforce the management of elective C-Section in resident women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03708-6.

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.