Midwives' experiences of professional learning when practicing collegial midwifery assistance during the active second stage of labour: data from the oneplus trial

BACKGROUND

Learning is a lifelong process and the workplace is an essential arena for professional learning. Workplace learning is particularly relevant for midwives as essential knowledge and skills are gained through clinical work. A clinical practice known as 'Collegial Midwifery Assistance' (CMA), which involves two midwives being present during the active second stage of labour, was found to reduce severe perineal trauma by 30% in the Oneplus trial. Research regarding learning associated with CMA, however, is lacking. The aim was to investigate learning experiences of primary and second midwives with varying levels of work experience when practicing CMA, and to further explore possible factors that influence their learning.

METHODS

The study uses an observational design to analyse data from the Oneplus trial. Descriptive statistics and proportions were calculated with 95% confidence intervals. Stratified univariable and multivariable logistic regression analysis were performed.

RESULTS

A total of 1430 births performed with CMA were included in the study. Less experienced primary midwives reported professional learning to a higher degree (< 2 years, 76%) than the more experienced (> 20 years, 22%). A similar but less pronounced pattern was seen for the second midwives. Duration of the intervention ≥ 15 min improved learning across groups, especially for the least experienced primary midwives. The colleague's level of experience was found to be of importance for primary midwives with less than five years' work experience, whereas for second midwives it was also important in their mid to late career. Reciprocal feedback had more impact on learning for the primary midwife than the second midwife.

CONCLUSIONS

The study provides evidence that CMA has the potential to contribute with professional learning both for primary and second midwives, for all levels of work experience. We found that factors such as the colleague's work experience, the duration of CMA and reciprocal feedback influenced learning, but the importance of these factors were different for the primary and second midwife and varied depending on the level of work experience. The findings may have implications for future implementation of CMA and can be used to guide the practice.

[Update on the management modalities of expulsive efforts during childbirth]

The second stage of labour includes both the passive and active stages, involving expulsive efforts. The management of this phase of labour aims to minimise the maternal and neonatal complications that could be associated with a prolonged active2nd stage, but also to limit medical interventions. On the maternal side, prolonged duration of expulsive effort appears to be correlated with increased postpartum haemorrhage, perineal injury and, in the long term, urinary and anal incontinence. From a neonatal viewpoint, expulsive efforts carry risks of neonatal acidosis, asphyxia, admission to the neonatal intensive care unit and trauma. Optimal management of expulsive efforts involves several strategies. Various aspects need to be addressed in order to optimise this management, including the timing of the start of expulsive efforts, comparing immediate pushing with delayed pushing, and the duration of expulsive efforts. In addition, it is important to examine the different pushing modalities, whether intense or moderate, using open or closed-glottis pushing, as well as the maternal position during pushing. According to the current literature, no specific technique or predefined duration appears to reduce the risk of neonatal or maternal complications. It therefore seems essential to adopt an individualised approach for each woman, placing her at the centre of the care and decision-making process, in order to take account of her preferences during childbirth.

Women's experiences of being assisted by two midwives during the active second stage of labour: Secondary outcomes from the Oneplus trial

BACKGROUND

'Collegial Midwifery Assistance' (CMA) is a clinical practice aiming to reduce severe perineal trauma (SPT) during childbirth. This practice involves two midwives being present during the active second stage of labour rather than one, which is the case in standard care. The effectiveness of CMA was evaluated in the Oneplus trial and a 30% reduction in SPT was shown.

AIM

The aim was to investigate the experience of women who received the CMA intervention in the trial and to explore factors influencing their experiences.

METHODS

A cohort study using data from the Oneplus trial and a one-month postpartum follow-up questionnaire. Descriptive statistics, univariable and multivariable logistic regression analyses were performed.

RESULTS

A total of 1050 women who received the CMA intervention responded to the questionnaire. Of these, 35.8% reported that they strongly agreed with feeling safe during the second stage of labour and 42.6% were inclined to have an additional midwife present at a subsequent birth. The intervention was favourably received by women who experienced fear of birth, who were non-native Swedish speakers, and had lower educational attainment. Furthermore, women were more positive towards CMA the longer the intervention lasted.

CONCLUSIONS

The results of this study suggest that the CMA intervention is accepted well by women and can be safely implemented into standard care. The duration of the CMA intervention was an important factor that influenced women's experiences and should be used to guide future practice.

Perineal massage and warm compresses - Randomised controlled trial for reduce perineal trauma during labor

OBJECTIVE

The aim of this study is to evaluate the effect of perineal massage and warm compresses technique on the perineum integrity during second stage of labor.

DESIGN AND SETTING

A single-center, prospective, randomized controlled trial was conducted between March 1st, 2019, and December 31st, 2020, at Hospital of Braga.

PARTICIPANTS

Women with 18 years or older, between 37 weeks and 41 weeks pregnant, in whom a vaginal birth of a fetus in the cephalic presentation was planned were recruited. Eight hundred forty-eight women were randomly assigned (Perineal massage and warm compresses group, n = 424 and control group, n = 424), and 800 women, both perineal massage and warm compresses group (n = 400) and control group (n = 400) were included in the strict per protocol analysis.

INTERVENTION

In the perineal massage and warm compresses group, women received perineal massage and warm compresses and in the control group, women received hands-on technique.

RESULTS

The incidence of intact perineum was significantly higher in the perineal massage and warm compresses group [perineal massage and warm compresses group: 47% vs control group: 26.3%; OR 2.53, 95% CI 1.86-3.45, p<0.001], whereas second-degree tears and episiotomy rate were significantly lower in this group [perineal massage and warm compresses group: 7.2% vs control group: 12.3%; OR 1.96, 95% CI 1.17-3.29, p = 0.010 and perineal massage and warm compresses group: 9.5% vs control group: 28.5%; OR 3.478, 95% CI 2.236-5.409, p<0.001, respectively]. Also, obstetric anal sphincter injury with and without episiotomy and second-degree tears with episiotomy were significantly lower in the perineal massage and warm compresses group [perineal massage and warm compresses group: 0.5% vs control group: 2.3%; OR 5.404, 95% CI 1.077-27.126, p = 0.040 and perineal massage and warm compresses group: 0.3% vs control group: 1.8%; OR 9.253, 95% CI 1.083-79.015, p = 0.042, respectively].

CONCLUSIONS

The perineal massage and warm compresses technique increased the incidence of intact perineum and reduced the incidence of second-degree tear, episiotomy and obstetric anal sphincter injury.

IMPLICATIONS FOR PRACTICE

Perineal massage and warm compresses technique is feasible, inexpensive and reproductible. Therefore, this technique should be taught and trained to midwives students and midwives team. Thus, women should have this information and have the option to decide whether they want to receive the perineal massage and warm compresses technique in the second stage of labor.

Maternal and perinatal outcomes of prolonged second stage of labour: a historical cohort study of over 51,000 women

BACKGROUND

Prolonged second stage of labour has been associated with adverse maternal and perinatal outcomes. The maximum length of the second stage from full dilatation to birth of the baby remains controversial. Our aim was to determine whether extending second stage of labour was associated with adverse maternal and perinatal outcomes.

METHODS

A retrospective cohort study was conducted using routinely collected hospital data from 51592 births in Aberdeen Maternity Hospital between 2000 and 2016. The hospital followed the local guidance of allowing second stage of labour to extend by an hour compared to national guidelines since 2008 (nulliparous and parous). The increasing duration of second stage of labour was the exposure. Baseline characteristics, maternal and perinatal outcomes were compared between women who had a second stage labour of (a) ≤ 3 h and (b) > 3 h duration for nulliparous women; and (a) ≤ 2 h or (b) > 2 h for parous women. An additional model was run that treated the duration of second stage of labour as a continuous variable (measured in hours). All the adjusted models accounted for: age, BMI, smoking status, deprivation category, induced birth, epidural, oxytocin, gestational age, baby birthweight, mode of birth and parity (only for the final model).

RESULTS

Each hourly increase in the second stage of labour was associated with an increased risk of obstetric anal sphincter injury (aOR 1.21 95% CI 1.16,1.25), having an episiotomy (aOR 1.48 95% CI 1.45, 1.52) and postpartum haemorrhage (aOR 1.27 95% CI 1.25, 1.30). The rates of caesarean and forceps delivery also increased when second stage duration increased (aOR 2.60 95% CI 2.50, 2.70, and aOR 2.44 95% CI 2.38, 2.51, respectively.) Overall adverse perinatal outcomes were not found to change significantly with duration of second stage on multivariate analysis.

CONCLUSIONS

As the duration of second stage of labour increased each hour, the risk of obstetric anal sphincter injuries, episiotomies and PPH increases significantly. Women were over 2 times more likely to have a forceps or caesarean birth. The association between adverse perinatal outcomes and the duration of second stage of labour was less convincing in this study.

Techniques for managing an impacted fetal head at caesarean section: A systematic review

A complication arising at caesarean birth when the baby's head is deeply engaged in the pelvis and may be difficult to deliver, is known as an 'impacted fetal head'. This obstetric emergency occurs in 16% of second stage caesarean sections. Multiple techniques are described in the literature to manage the complication but there is no consensus regarding which technique results in the best maternal and neonatal outcomes. The objective of this review is to determine which technique for managing impacted fetal head at caesarean section has the best maternal and neonatal outcomes. A literature search of three electronic databases was conducted in November 2021. Studies directly comparing two methods for the management of impacted fetal head at caesarean section in the second stage were included. Systematic reviews, meta-analyses, case-control studies, and studies not fitting the search criteria were excluded. Data was extracted in Covidence and meta-analysis of the six most commonly reported outcomes was conducted using RevMan 5.4. In total, 16 studies (3344women) were included. 13 studies (2506women) compared the push method with reverse breech extraction. meta-analysis showed that risk of extension of the uterine incision, blood transfusion, bladder injury, postpartum haemorrhage, NICU admission and Apgar score <7 at 5 min were significantly higher with the push method compared with reverse breech extraction. Three studies (838women) compared the push method with Patwardhan's technique. meta-analysis of studies comparing the push method with Patwardhan's technique found no significant differences between the two groups in any of the six maternal or neonatal outcomes. Evidence derived from small, inadequately powered studies suggests reverse breech extraction is associated with better outcomes than the push method. The method which produces the best outcomes is still unknown as not all methods have been tested. Further high quality, adequately powered RCTs are warranted for definitive conclusions to be drawn and to ameliorate the paucity of evidence on how best to manage this complication.

Benefits and risks of spontaneous pushing versus directed pushing during the second stage of labour among women without epidural analgesia: A systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review and meta-analysis was to assess the benefits and risks of spontaneous pushing and directed pushing used by labouring women without epidural analgesia during the second stage labour.

DESIGN

Systematic review and meta-analysis.

METHODS

Randomised controlled trials published in PubMed/ MEDLINE, CINAHL, Web of Science, Scopus, EMBASE, psycINFO, the Cochrane Library, and four Chinese databases were systematically searched from their inception to December, 2021. Grey literature were also searched. Two authors independently screened the literature and evaluated the quality of the included studies.

RESULTS

Ten studies with a total of 1510 women were pooled. Spontaneous pushing in the second stage of labour reduced the rates of Caesarean section and extended episiotomy. The difference was significant among spontaneous pushing group and directed pushing group, with relative risk and 95% confidence intervals of 0.42 and 0.19-0.94, 0.49 and 0.29-0.82, respectively. There was no significant difference in the duration of the second stage of labour, rates of spontaneous vaginal birth and newborn outcomes.

CONCLUSION

The results of this meta-analysis demonstrate that spontaneous pushing during the second stage of labour results in at least the same maternal and newborn outcomes, lower Caesarean section rates and lower incidence of extended episiotomy.

Is there an association between the length of the second stage of labour and urinary incontinence in multiparous women?

OBJECTIVES

It is unclear whether the length of the second stage of labour plays a role in the development of urinary incontinence (UI). This study aimed to investigate the association between the cumulative length of the second stage of labour in multiparous women and UI.

METHODS

This was a longitudinal cohort study of women who had undergone three vaginal deliveries (VDs) between 2008 and 2017. UI was assessed using the Urinary Distress Inventory (UDI-6) questionnaire. Women with a cumulative length of the second stage of labour for three deliveries in the upper 90th percentile (study group) were compared with women with a cumulative length of the second stage of labour below the 90th percentile (control group). A sample size of 280 women was needed to detect a 15-point difference in the UDI-6 score between the groups.

RESULTS

Thirty-one women were included in the study group and 275 women were included in the control group. Demographic and obstetric characteristics were similar in both groups. There was no between-group difference in mean UDI-6 score: 12.3 ± 17.5 in the study group and 14.9 ± 18.2 in the control group (p = 0.55). No association was found between the cumulative length of the second stage of labour and the UDI score. A linear regression model revealed that maternal body mass index was independently associated with UDI-6 score (correlation coefficient 0.67, 95% confidence interval 0.19-1.15; p = 0.006).

CONCLUSION

The cumulative length of the second stage of labour in multiparous women is not associated with UI.

Unusual neurological presentation of second stage African trypanosomiasis in a young boy: a case report

BACKGROUND

In South Sudan, sleeping sickness is a frequent condition caused by human African trypanosomiasis. There are two stages that are well-known. When the CNS is affected, especially with Trypanosoma gambiense infection, the early hemolymphatic stage and the late encephalitic stage have been observed, including mental, motor, and sensory symptoms. In this case, second-stage African trypanosomiasis manifested itself in an atypical neurological manner.

CASE PRESENTATION

A 16-year-old boy from South Sudan referred to Sudan National Centre for Neurological Sciences, Khartoum, Sudan suffering from non-convulsive status epilepticus, mental deterioration and behavioral changes for the last nine months. He was conscious but disorientated. Low hemoglobin concentration, elevated ESR, enlarged spleen and positive card agglutination test for trypanosomiasis was found in this patient. Electro-encephalogram (EEG) found an on-going generalized seizure activity. The patient showed improvement after management with carbamazepine and tonic.

CONCLUSION

Our case highlights that late second stage African trypanosomiasis with neurological complications such as non-convulsive status epilepticus should be suspected in any patient who developed progressive cognitive decline and behavioral changes following long standing history of African Trypanosomiasis and routine Electro-encephalogram EEG is the best tool to diagnose non convulsive status epilepticus.

Associations between prolonged second stage of labor and maternal and neonatal outcomes in freestanding birth centers: a retrospective analysis

BACKGROUND

Current guidelines for second stage management do not provide guidance for community birth providers about when best to transfer women to hospital care for prolonged second stage. Our goal was to increase the evidence base for these providers by: 1) describing the lengths of second stage labor in freestanding birth centers, and 2) determining whether proportions of postpartum women and newborns experiencing complications change as length of second stage labor increases.

METHODS

This study is a retrospective analysis of de-identified client-level data collected in the American Association of Birth Centers Perinatal Data Registry, including women giving birth in freestanding birth centers January 1, 2007 to December 31, 2016. We plotted proportions of postpartum women and newborns transferred to hospital care against length of the second stage of labor, and assessed significance of these with the Cochran-Armitage test for trend or chi-square test. Secondary maternal and newborn outcomes were compared for dyads with normal and prolonged second stages of labor using Fisher's exact test.

RESULTS

Second stage labor exceeded 3 hours for 2.3% of primiparous women and 2 hours for 6.6% of multiparous women. Newborn transfers increased as second stage increased from < 15 minutes to > 2 hours (0.6% to 6.33%, p for trend = 0.0008, for primiparous women, and 1.4% to 10.6%, p for trend < 0.0001, for multiparous women.) Postpartum transfers for multiparous women increased from 1.4% after second stage < 15 minutes to greater than 4% for women after second stage exceeding 2 hours (p for trend < 0.0001.) CONCLUSIONS: Complications requiring hospitalization of postpartum women and newborns become more common as the length of the second stage increases. Birth center guidelines should consider not just presence of progress but also absolute length of time as indications for transfer.

Second stage expedite delivery of low birth weight neonates: Emergent cesarean delivery versus vacuum assisted delivery

OBJECTIVE

To determine maternal and neonatal outcomes among women undergoing second stage emergent cesarean delivery (ECD) versus vacuum-assisted delivery (VAD) of low birthweight neonates.

MATERIALS AND METHODS

A retrospective cohort study from two tertiary medical centers. We included women who underwent either ECD or VAD during the second stage of labor, and delivered neonates with a birthweight of <2500 g during 2011-2019. Characteristics and outcomes were compared between the groups. The primary outcome was the rate of a composite adverse neonatal outcome, defined as the presence of ≥1 of the following: Apgar 5 min < 7, respiratory distress syndrome, neonatal intensive care unit admission, mechanical ventilation and intrapartum fetal death.

RESULTS

The study cohort included 611 patients, of whom 46 had ECD and 565 had VAD. Baseline characteristics did not differ between the groups. The rate of Apgar score < 7 at 1 min was higher among the ECD group]10 (22%) vs. 29 (5%), OR (95% CI) 5.1 (2.3-11.3), p < 0.001[. Other neonatal and maternal outcomes were similar in both groups.

CONCLUSIONS

Neonatal and maternal outcomes do not differ substantially between ECD and VAD of neonates weighing <2500 g. This information may be useful when contemplating the preferred mode of delivery in this setting.

How I do it - Second stage revision total knee arthroplasty

BACKGROUND

Infection is a potentially devastating complication following primary total knee arthroplasty, and the traditional gold-standard treatment for chronic prosthetic joint infection has been in the form of a two-stage revision total knee arthroplasty. This involves a first stage - removal of all implants and infected material, with implantation of a temporary spacer - followed by a second stage which includes reimplantation with a definitive prosthesis.

INDICATIONS

Although the outcomes of single-stage and two-stage revision arthroplasty surgeries are similar, there are certain indications such as atypical or more virulent organisms, patient factors and soft tissue factors that would favour a two-stage approach.

SURGICAL TECHNIQUE

The second stage revision procedure consists of explantation of the spacer with a debridement and synovectomy. Further samples are sent for microbiological analysis. Once the surgical field is clean and lavaged, the definitive prosthesis is implanted.

CONCLUSIONS

A second stage revision total knee arthroplasty is a reliable procedure for the treatment of chronic prosthetic joint infection. There is a significant re-revision rate, predominantly due to recurrent deep infection.

The safety and efficacy of autologous fat grafting during second stage breast reconstruction

BACKGROUND

Patients often pursue revisions following implant-based breast reconstruction (IBR) to achieve their desired result. Fat grafting is a popular choice for patients and can be performed at second stage reconstruction or at a future date as a revisionary surgery. We investigate the best time to fat graft in IBR by comparing the outcomes of patients who received fat grafting during implant placement with those who pursued fat grafting during a tertiary procedure.

METHODS

We retrospectively reviewed the charts of 157 patients (270 breasts) who underwent immediate two-stage IBR and fat grafting over a five-year period (2012-2016) at our institution. Two cohorts were created based on timing of first fat grafting procedure: immediate (IFG) and delayed (DFG). Charts were reviewed for postoperative complications or revisions.

RESULTS

Complication rates were lower when fat grafting was performed during the second stage (p = 0.0331). Patients in the DFG cohort required more than one additional revision (p < 0.001) until the completion of reconstruction. Patients in the IFG cohort completed their reconstruction and revisions more than one year earlier than the DFG cohort (p < 0.001). Multivariable regressions showed IFG to be associated with decreased revisions (p < 0.001) and total fat grafting procedures (p = 0.008).

CONCLUSIONS

These results indicate that fat grafting at the second stage does not increase overall complication rates, require fewer additional surgeries, and enables patients to reach their desired aesthetic appearance in a shorter time frame. Fewer total surgeries translate not only to a more economical option but also obviate the risk of complications that come with additional surgeries.

The length of the second stage of labor in nulliparous, multiparous, grand-multiparous, and grand-grand multiparous women in a large modern cohort

OBJECTIVE

The objectives of this study were to characterize the length of the second stage of labor in a large contemporary cohort of women with varying obstetrical histories and to investigate the factors associated with the length of the second stage.

STUDY DESIGN

This was a retrospective cohort study conducted at a tertiary medical center. Women with singleton spontaneous vaginal deliveries between the years 2005-2017 were included. The length of the second stage was compared between groups based on obstetrical history and maternal and obstetrical characteristics were evaluated to identify factors associated with the length of the second stage.

RESULTS

There were 100,759 deliveries included in the study. The second stage of labor was longest in nulliparous women with an epidural (median 96 min, interquartile range 53-142 min), which was 57 min longer than in nulliparous women without an epidural. In parous, grand-multiparous, grand-grand multiparous, and women with a prior cesarean delivery, all without an epidural, there was no clinically significant difference in the length of the second stage (median 6-7 min). The length of the second stage was significantly shorter in women delivering preterm compared to women delivering at term. Birthweight, previous cesarean delivery, gestational age, use of epidural analgesia, and induction of labor were all independently positively associated with the length of the second stage, while parity was negatively associated with the length of the second stage.

CONCLUSION

The median length of the second stage of labor was considerably longer than historically described in nulliparous women and relatively shorter in parous women.

The effect of antenatal pelvic floor muscle exercises on labour and birth outcomes: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

The current data on the effectiveness of antenatal pelvic floor muscle exercises (PFME) on childbirth outcomes are limited. Therefore, in this study the effect of antenatal PFMEs on labour and birth outcomes was assessed by undertaking a meta-analysis.

METHODS

Databases were systematically searched from 1988 until June 2019. Randomised controlled trials (RCTs) and quasi-experimental studies were included. The methodological quality of studies was assessed using Cochrane Collaboration tools. The outcomes of interest were: duration of first and second stage of labour, episiotomy and perineal outcomes, mode of birth (spontaneous vaginal birth, instrumental birth and caesarean section) and fetal presentation. The mean difference (MD) and risk ratio RR) with the corresponding 95% confidence intervals (CIs) were calculated to assess the association between PFME and the childbirth outcomes.

RESULTS

A total of 16 articles were included (n = 2,829 women). PFME shortened the duration of the second stage of labour (MD: -20.90, 95%, CI: -31.82 to -9.97, I²: 0%, p = 0.0002) and for primigravid women (MD: -21.02, 95% CI: -32.10 to -9.94, I²: 0%, p = 0.0002). PFME also reduced severe perineal lacerations (RR 0.57, 95% CI: 0.38 to 0.84, I²: 30%, p = 0.005). No significant difference was seen in normal vaginal birth, caesarean section, instrumental birth and episiotomy rate. Most of the studies carried a moderate to high risk of bias.

CONCLUSION

Antenatal PFME may be effective at shortening the second stage of labour and reducing severe perineal trauma. These findings need to be interpreted considering the included studies' risk of bias. More high-quality RCTs are needed.

Comparison of outcomes at full-dilation cesarean section with and without the use of a fetal pillow device

OBJECTIVE

To identify whether use of the fetal pillow device resulted in a reduction in intraoperative complications, such as uterine incision extension, requirement for breech extraction, etc. Other maternal outcomes (duration of hospital stay, requirement for blood transfusion, and requirement for return to hospital or operating theatre) were also reviewed. Neonatal outcomes of APGAR-5, arterial pH, and requirement for intensive care admission were assessed.

METHODS

A retrospective cohort analysis was completed for fully dilated cesarean deliveries completed between January 2014 and December 2018 at Ipswich Hospital, Australia. In total, 174 patient records were identified (114 with pillow, 60 without). Logistic and linear regressions were used to assess the outcomes associated with fetal pillow use.

RESULTS

There were no significant differences in operative complications between the pillow and no-pillow groups (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.26-1.22, P=0.146). Linear regression analysis showed a decrease in hospital length of stay (hours) (-9.4, 95% CI -17.80 to -0.99, P=0.029) and a higher neonatal arterial pH at delivery (0.06, 95% CI 0.03-0.09, P=0.0001) in the pillow group.

CONCLUSION

At full dilation cesarean, operative complications are not increased when employing the fetal pillow with maternal benefits of decreased hospitalization.

Evidence-based management of the second stage of labor

The second stage of labor is defined as the time from complete dilation of the cervix to delivery of the fetus. The objective of this seminar is to provide a contemporary, evidence-based approach to management of the second stage of labor. This seminar reviews background maternal and fetal characteristics that impact the duration of the second stage of labor, the recommended evidence-based management (e.g. immediate pushing, manual rotation, operative vaginal delivery), and the maternal/neonatal morbidity clinicians must consider when deciding between operative delivery and a prolonged second stage of labor.

Caesarean Delivery in the Second Stage of Labour at a Tertiary Care Hospital

Caesarean section performed in the second stage of labour has many implications for maternal and neonatal morbidity as well as for subsequent pregnancies. A study was conducted to analyse the indications and maternal and neonatal prognosis of caesarean sections performed in the second stage of labour. Four percentage of caesarean sections were performed in the second stage of labour; 60% of these were referred cases. Most common indication was non-descent of head. Forty-three percentage of newborns were admitted in the neonatal intensive care unit. Hospital stay was prolonged which further increased the hospital burden. A proper judgement is required by the obstetrician to take decision for instrumental delivery or caesarean section. Early diagnosis and timely referral with a good infrastructure would help to decrease the maternal and neonatal morbidity.

Warm perineal compresses during the second stage of labor for reducing perineal trauma: A meta-analysis

OBJECTIVE

Perineal trauma may have a negative impact on women's lives as it has been associated with perineal pain, urinary incontinence and sexual dysfunction. The aim of this systematic review and meta-analysis of randomized controlled trials was to evaluate the effectiveness of warm compresses during the second stage of labor in reducing perineal trauma.

METHODS

Electronic databases were searched from inception of each database to May 2019. Inclusion criteria were randomized trials comparing warm compresses (i.e. intervention group) with no warm compresses (i.e. control group) during the second stage of labor. Types of participants included pregnant women planning to have a spontaneous vaginal birth at term with a singleton in a cephalic presentation. The primary outcome was the incidence of intact perineum. Meta-analysis was performed using the Cochrane Collaboration methodology with results being reported as relative risk (RR) with 95% confidence interval (CI).

RESULTS

Seven trials, including 2103 participants, were included in this meta-analysis. Women assigned to the intervention group received warm compresses made from clean washcloths or perineal pads immersed in warm tap water. These were held against the woman's perineum during and in between pushes in second stage. Warm compresses usually started when the baby's head began to distend the perineum or when there was active fetal descent in the second stage of labor. We found a higher rate of intact perineum in the intervention group compared to the control group (22.4% vs 15.4%; RR 1.46, 95% CI 1.22 to 1.74); a lower rate of third degree tears (1.9% vs 5.0%; RR 0.38, 95% CI 0.22 to 0.64), fourth degree tears (0.0% vs 0.9%; RR 0.11, 95% CI 0.01 to 0.86) third and fourth degree tears combined (1.9% vs 5.8%; RR 0.34, 95% CI 0.20 to 0.56) and episiotomy (10.4% vs 17.1%; RR 0.61, 95% CI 0.51 to 0.74).

CONCLUSION

Warm compresses applied during the second stage of labor increase the incidence of intact perineum and lower the risk of episiotomy and severe perineal trauma.

Panzi score as a parsimonious indicator of urogenital fistula severity derived from Goh and Waaldijk classifications

OBJECTIVE

To derive a comprehensive system that allows a single score to define relative fistula severity.

METHODS

The present observational study included women with urogenital fistula treated at the Panzi Hospital, Democratic Republic of Congo, or its outreach clinics across the Democratic Republic of Congo between September 1, 2013, and December 31, 2014. Fistula severity was assessed by Goh and Waaldijk classifications and surgical success was ascertained. Logistic regression was used to select fistula characteristics predictive of surgical failure, and to preliminarily verify the newly derived Panzi score.

RESULTS

Overall, 837 women were included in the analysis. Goh or Waaldijk fistula descriptors associated with a higher probability of poor surgical outcomes in the unadjusted bivariate analysis were circumferential defect (P=0.007), proximity to the external urethral orifice (P=0.001), and size (P=0.001). These fistula characteristics were used to construct the Panzi score, which varied from 3 (most severe) to 0 (minor fistula). For each increase above 0, the odds of surgical failure increase by a factor of 1.65 (P<0.001).

CONCLUSION

The Panzi score of urogenital fistula provided a data-driven, simple, comprehensive, and parsimonious score. It could be used to report group data, to provide continuous level data for use in higher order statistics, and to resolve issues such as the cut-off point for referring women to hospital in accordance with fistula complexity.

Factors associated with obstetric anal sphincter injuries in midwife-led birth: A cross sectional study

INTRODUCTION

Obstetric anal sphincter injurie (OASI) in vaginal births are a serious complication, and are associated with maternal morbidity. Focus on modifiable factors in midwives clinical skills and competences contributing to prevent the occurrence of OASI are essential. The objective of this study was to investigate the association between OASI and factors related to midwife-led birth such as manual support of perineum, active delivery of baby's shoulders, maternal birth position, and pushing and breathing techniques in second stage of labour.

METHODS

A prospective cross sectional study including primiparous (n = 129) and multiparous (n = 628) women in midwife-led non-instrumental deliveries with OASI (n = 96) or intact perineum (n = 661). Data were collected in a university hospital in Norway with two different birth settings: an alongside midwife-led unit with approximately 1500 births per year and an obstetrical unit with approximately 3500 births per year. In midwife-led births, there were a total of 2.6% OASI and 18.9% intact perineum.

RESULTS

The sample consisted of 757 women, 12.7% suffered OASI and 87.3% of participating women had an intact perineum. This selected sample compares the most serious outcome (OASI), and the optimal outcome (intact perineum).In primiparous women, 61 women suffered OASI and 68 women had intact perineum, while for multipara women, 35 women suffered OASI and 593 women had intact perineum. There was an increased risk of OASI if women actively pushed when the head was crowning compared to breathing the head out (adjusted OR: 3.10; 95% CI: 1.75 to 5.47). The maternal birth position associated with the lowest risk of OASI was kneeling position (adjusted OR: 0.15; 95% CI: 0.03 to 0.70), supine maternal birth position (adjusted OR: 2.52; 95% CI: 1.04 to 4.90) and oxytocin augmentation more than 30 min in second stage (OR: 1.93; 95% CI: 1.68 to 15.63) were associated with an increased risk of OASI, when adjusting for maternal, foetal, and obstetric factors.

CONCLUSION

Our study suggests that actively pushing when the baby's head is crowning, a supine maternal birth position and oxytocin augmentation more than 30 min in second stage, were associated with increased risk of OASI when compared to intact perineum. A kneeling maternal birth position was associated with a decreased risk of OASI.

The effect of perineal massage during the second stage of birth on nulliparous women perineal: A randomization clinical trial

Background

Childbirth and puerperium are of the most important periods in women's lives and can affect different aspects of their lives.

Objective

To determine the effect of perineal massage in the second stage of labor on perineal lacerations, episiotomy, and perineal pain in nulliparous women.

Methods

This randomization clinical trial was conducted at Be'sat Hospital in Sanandaj, Iran, from 2013 to 2014. A total of 195 nulliparous women were included in the study. The participants were selected through convenience sampling, and randomly assigned to two groups: intervention and control groups. The intervention group received 30-minute perineal massage during second stage of labor. Subsequently, we analyzed perineal laceration, episiotomy, and perineal pain among the two groups. All of them were taught about postpartum perineal pain and its severity, and the researcher followed them up 3 days, 10 days, and 3 months after childbirth by telephone. The data were analyzed using SPSS version 18. We used descriptive statistics and analytical statistics, including t test, Chi-square test, and Fisher's test.

Results

Frequency of episiotomy was 69.47% in the intervention group and 92.31% in the control group, and the difference was statistically significant (p<0.05). The results revealed 23.16% of first-degree perineal laceration and 2.11% of second-degree perineal laceration in the intervention group, and no vestibular laceration or third- and fourth-degree lacerations in the intervention group. However, there were 5.13% of vestibular laceration, 7.69% of first-degree laceration, 2.56% of second-degree laceration, and 1.05% of third-degree laceration (one woman) in the control group. Based on the results, the postpartum perineal pain was significantly different in both groups.

Conclusion

Regarding the results of this study and those of other studies, perineal massage during the second stage of labor can reduce the need to episiotomy, perineal injuries, and perineal pain.

Trial registration

The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the Irct.ID: IRCT2013090314556N1.

Funding

This study received by financial support of Kurdistan University of Medical Sciences, Sanandaj, Iran.

A cross-sectional study exploring the incidence of and indications for second-stage cesarean delivery over three decades

OBJECTIVE

To observe the incidence of, indications for, and complications associated with second-stage cesarean delivery in 10-year intervals over 30 years.

METHODS

The present analysis of prospectively collected data compared cesarean deliveries during 1976, 1986, 1996, and 2006 at John Radcliffe Hospital in Oxford, UK (n=3222). Pregnancy, delivery, and neonatal details were reviewed.

RESULTS

The proportion of deliveries by cesarean in the second stage of labor increased from 0.5% (22/4464) in 1976 to 2.1% (124/5998) in 2006 (P<0.001). The proportion of cesarean deliveries during the second stage because of failed instrumental delivery also increased over the study period from 59.1% (13/22) in 1976 to 71.0% (88/124) in 2006. Compared with cesareans at other stages, uterine trauma (P<0.001), blood loss greater than 1000 mL (P=0.002), and blood transfusion (P=0.001) were more frequent in second-stage cesarean delivery. Neonates delivered by second-stage cesarean had lower Apgar scores (P<0.001 for 1-min and 5-min scores) and cord arterial pH values (P<0.001) than did those delivered by cesarean earlier in labor. A trend towards an increase in neonatal trauma with second-stage cesarean compared with cesarean delivery before labor or during the first stage did not reach statistical significance.

CONCLUSION

The proportion of deliveries by cesarean in the second stage of labor increased; these deliveries were associated with greater maternal and neonatal morbidity, but were not influenced by the indication for cesarean.

A retrospective comparison study of the infra-mammary approach to the standard mastectomy scar in the 2nd stage of tissue expander to implant breast reconstruction

BACKGROUND

Staged expander-to-implant breast reconstruction is plagued by a high prevalence of complications. We have employed an alternative approach of using the infra-mammary crease (IMF) for expander-to-implant exchange. The IMF approach was thought to utilize healthier tissues, which are believed to be less affected by the process of tissue expansion, and reside distant from the field of the radiotherapy boost.

METHODS

A retrospective chart review was performed on all patients undergoing a staged implant-based breast reconstruction from 2009 to 2014. Patients were divided into those that received an IMF vs. a mastectomy scar (MS) approach in the second stage of expander-to-implant exchange. Patient characteristics and postoperative complications were extracted.

RESULTS

A total of 75 patients undergoing 96-staged reconstructions were included (70 cases MS vs. 26 cases IMF). Patient demographics and implant characteristics were similar between groups. There were no significant differences in overall complications between the groups (11.4% MS vs. 7.7% IMF, P=0.72). All cases of implant exposure occurred in the MS group and had a history of radiation. However, there was no statistical difference in implant exposure between groups (4.3% MS vs. 0% IMF, P=0.56) or in the irradiated patients subgroup (20% MS vs. 0% IMF, P=0.25).

CONCLUSIONS

In conclusion, the IMF approach for the second stage of expander-to-implant exchange is an alternative technique with a similar prevalence of complications as the traditional mastectomy scar approach. This technique may prove useful in reducing postoperative incisional dehiscence and implant exposure, especially in the context of radiotherapy.

Cardiotocographic findings in the second stage of labor among fetuses delivered with acidemia: a comparison of two classification systems

BACKGROUND

The RCOG classification system of CTG trace is widely used for the analysis of the fetal heart rate during the first and second stage of labor. Other authors proposed specific classification systems for the second stage traces.

OBJECTIVE

To evaluate the accuracy of RCOG and Piquard cardiotocographic patterns classification systems in predicting fetal acidemia in the second stage of labor.

STUDY DESIGN

This was a nested retrospective case-control study including fetuses delivered with metabolic acidemia in the second stage of labor and a matched group of non-acidemic fetuses as controls. Cases and controls were selected from the electronic medical records of the University Hospital of Bologna between 2008 and 2013. The last 60min of the cardiotocograms recorded during the second stage of labor were independently classified by a senior consultant and a trainee according to RCOG and Piquard classifications. The inter-observer agreement and the accuracy of the two classifications in predicting fetal acidemia were evaluated.

RESULTS

In all, 82 acidemic fetuses and 164 controls were recruited in the study period. Regarding the CTG traces assessment, the inter-observer agreement was moderate for both the categorizations (RCOG κ=0.584). Unclassifiable CTG patterns were more frequent among acidemic fetuses vs controls either at RCOG and at Piquard evaluation (26.8% vs 7.9%, p<0.001). Both systems yielded a moderate and comparable ability to predict fetal acidemia (RCOG ROC AUC=0.731; 95% CI 0.660-0.795; Piquard ROC AUC=0.773; 95% CI 0.704-0.833. DeLong z-test=1.186, p=0.236).

CONCLUSIONS

RCOG and Piquard systems have a moderate accuracy in identifying acidemic fetuses during the second stage of labor. The occurrence of unclassifiable findings seems significantly more common among the acidemic fetuses.

First versus second stage C/S maternal and neonatal morbidity: a systematic review and meta-analysis

The rates of cesarean section at full cervical dilatation (second stage cesarean sections) are currently increasing. The purpose of the present study is to compare maternal and neonatal morbidity and mortality among cases offered cesarean section at full dilatation to those offered cesarean section prior to full dilatation. We searched Medline, Scopus, Clinicaltrials.org, Popline, Cochrane CENTRAL, and Google Scholar search engines, along with reference lists from all included studies. The RevMan 5.0 software was used for all analyses. Primary maternal outcomes were defined as death, ICU admission and need for transfusion, while primary neonatal outcomes were defined as death, neonatal unit admission and 5min Apgar score less than 7. Ten studies were finally retrieved involving 23,104 singleton childbearing women (18,160 operated in the first stage and 4944 in the second stage of labor). Second stage cesarean section seems to lead to higher maternal admissions to ICU (OR 7.41, 95% CI 2.47-22.5) and higher transfusion rates (OR 2.60, 95% CI 1.49-2.54). Neonatal death rates were also increased (OR 5.20, 95% CI 2.49-10.85) along with admissions to neonatal unit (OR 1.63, 95% CI 0.91-2.91) and rates of Apgar score less than 7 in 5min (OR 2.77, 95% CI 1.02-7.50). Second stage cesarean section seems to result significantly increased morbidity for both mothers and neonates. It seems that a direct evaluation with forceps and vacuum extractors is imperative in order to establish its place in modern evidence-based practice.

Early pushing urge in labour and midwifery practice: a prospective observational study at an Italian maternity hospital

OBJECTIVE

to investigate the early pushing urge (EPU) incidence in one maternity unit and explore how it is managed by midwives. The relation to some obstetric outcomes was also observed but not analysed in depth.

DESIGN

prospective observational study.

SETTING

Italian maternity hospital.

SAMPLE

60 women (44 nullips and 16 multips) experiencing EPU during labour.

FINDINGS

the total EPU incidence percentage was 7.6%. The single midwives' incidences range had a very wide margin, noting an inverse proportion between the number of diagnoses of EPU and midwife's waiting time between urge to push and vaginal examination. Two care policies were adopted in relation to the phenomenon: the stop pushing technique (n=52/60) and the 'let the woman do what she feels' technique (n=8/60). In case of stop pushing techniques, midwives proposed several combined techniques (change of maternal position, blowing breath, vocalisation, use of the bath). The EPU diagnosis at less than 8cm of cervical dilatation was associated with more medical interventions. Maternal and neonatal outcomes were within the range of normal physiology. An association between the dilatation at EPU diagnosis and obstetric outcomes was observed, in particular the modality of childbirth and perineal outcomes.

CONCLUSIONS AND IMPLICATION FOR PRACTICE

this paper contributes new knowledge to the body of literature around the EPU phenomenon during labour and midwifery practices adopted in response to it. Overall, it could be argued that EPU is a physiologic variation in labour if maternal and fetal conditions are good. Midwives might suggest techniques to woman to help her to stay with the pain, such as change of position, blowing breath, vocalisation and use of the bath. However, the impact of policies, guidelines and culture on midwifery practices of the specific setting are a limitation of the study because it is not representative of other similar maternity units. Thus, a larger scale work should be considered, including different units and settings. The optimal response to the phenomenon should be studied, considering EPU at different dilatation ranges. Future investigations could also focus on qualitative analysis of women and midwives' personal experience in relation to the phenomenon.