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Abstract
This is a retrospective review of 7398 deliveries under the direct care of the author over 25 years, from data input on personal handheld computers at the time of delivery. A more detailed look at 409 deliveries over 2.5 years where all the case notes were studied was also undertaken. The rate of cesarean section is outlined. For the last 10 years of the study, the rate of cesarean section was maintained at 19%. This was in quite an elderly population. Two main factors seemed responsible for the relatively low rate of cesarean: vaginal births after cesarean (VBACs) and rotational Kiwi deliveries.
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Affiliation(s)
- Mark Skehan
- University of Limerick Maternity Hospital, ULMH, Limerick, Ireland
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2
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Koenigbauer JT, Schalinski E, Jarchau U, Gauger U, Brandt K, Klaucke S, Scharf JP, Rath W, Hellmeyer L. Cervical ripening after cesarean section: a prospective dual center study comparing a mechanical osmotic dilator vs. prostaglandin E2. J Perinat Med 2021; 49:797-805. [PMID: 34333894 DOI: 10.1515/jpm-2021-0157] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/15/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Worldwide, the overall cesarean section is rising. Trial of labor after cesarean (TOLAC) is an overall safe option with an immediate impact on neonatal and maternal short- and long-term health. Since the use of prostaglandins in cervical ripening is associated with an increased risk of uterine rupture, mechanical methods as balloon catheters or osmotic dilators have been suggested for cervical ripening prior to induction of labour. Here we are analyzing and comparing the VBAC rate, as well as maternal and fetal outcome in cervical ripening prior to TOLAC. METHODS This prospective dual center study analyses maternal and neonatal outcomes of TOLAC in women with an unfavorable cervix requiring cervical ripening agent. The prospective application of an osmotic dilator (Dilapan-S, n=104) was analysed in comparison to the retrospective application of off-label dinoprostone (n=102). RESULTS The overall fetal and neonatal outcome revealed no significant differences in both groups. Patients receiving cervical ripening with the osmotic dilator delivered vaginally/by ventouse in 52% of cases, compared to 53% when using dinoprostone (p=0.603). The interval between application to onset of labor was significantly higher in the osmotic dilator group (37.9 vs.20.7 h, p=<0.001). However, time from onset of labor to delivery was similar in both groups (7.93 vs. 7.44 h, p=0.758). There was one case of uterine rupture in the dinoprostone group. CONCLUSIONS Our data shows that the application of the osmotic dilator leads to similar outcomes in VBAC rate and time from onset of labor to delivery as well as safety in both groups compared to off-label use dinoprostone. Cervical ripening using the mechanical dilator is a viable and effective option, without the risk of uterine hyperstimulation.
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Affiliation(s)
- Josefine Theresia Koenigbauer
- Department of Obstetrics and Gynecology, Vivantes Klinikum im Friedrichshain, Affiliate of Charité University, Berlin, Germany
| | - Elisabeth Schalinski
- Department of Obstetrics and Gynecology, Vivantes Klinikum im Friedrichshain, Affiliate of Charité University, Berlin, Germany
| | - Ute Jarchau
- Department of Obstetrics and Gynecology, Vivantes Klinikum im Friedrichshain, Affiliate of Charité University, Berlin, Germany
| | | | - Katrin Brandt
- Department of Obstetrics and Gynecology, Sana Klinikum Lichtenberg, Berlin, Germany
| | - Sandra Klaucke
- Department of Obstetrics and Gynecology, Sana Klinikum Lichtenberg, Berlin, Germany
| | - Jens-Peter Scharf
- Department of Obstetrics and Gynecology, Sana Klinikum Lichtenberg, Berlin, Germany
| | - Werner Rath
- Department of Obstetrics and Gynecology, University of Aachen, Aachen, Germany
| | - Lars Hellmeyer
- Department of Obstetrics and Gynecology, Vivantes Klinikum im Friedrichshain, Affiliate of Charité University, Berlin, Germany
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Deli T, Lampé R, Juhász AG, Kovács T, Daragó P, Bacskó G, Török O. How the cesarean delivery rate decreased at the Department of Obstetrics and Gynecology, University of Debrecen during the COVID-19 pandemic. Orv Hetil 2021; 162:811-823. [PMID: 34023814 DOI: 10.1556/650.2021.32241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 04/07/2021] [Indexed: 11/19/2022]
Abstract
Összefoglaló. Bevezetés: Az új koronavírus (SARS-CoV-2) okozta pandémia számos változást eredményezett életünk minden területén, így a debreceni Szülészeti és Nőgyógyászati Klinikán is. Célkitűzések: A koronavírus-járvány többek között a terminus körüli elektív szülésindukciók gyakorlatának megváltoztatását igényelte. A bevezetett új szakmai eljárásrendeknek, járványügyi intézkedéseknek, a megyei kórházi funkciót ellátó debreceni Kenézy Kórház Szülészeti Osztálya és a Szülészeti Klinika összevonásának, illetve a megváltozott jogi környezetnek a szülészeti ellátásra kifejtett együttes hatásait elemezzük. Módszerek: Helyi protokollokat és részletes eljárásrendeket készítettünk és vezettünk be. 1. Szülésindukció. 2. Szülésindukció cervixérlelést igénylő esetekben. 3. A szülés módjának megválasztása előzményi császármetszés után. 4. A császármetszés utáni hüvelyi szülést támogató, terminus körüli gondozási protokoll. A protokollok bevezetését követő első 9 hónap szülészeti mutatóit (szülésszám, császármetszések aránya, perinatalis kimenetel, szülésindukciók aránya és sikeressége) vizsgáltuk és hasonlítottuk össze a megelőző időszak debreceni adataival, illetve az országos szülészeti mutatókkal. Eredmények: Klinikánkon a császármetszés aránya 2020-ban 33,5%-ra csökkent, a protokollok bevezetése óta pedig 30,7%, miközben a 2020. évi magyarországi arány 40,3%. Az összes szülés 20%-a volt 2020-ban szülésindukció, melyek közül 74% végződött hüvelyi szüléssel, míg ugyanez 2019-ben 11% indukcióból 47%-nak adódott. A havi szülésszám 2020. január és 2021. január között folyamatosan emelkedett (250-ről 450-re), a havi császármetszési arány pedig 41%-ról 25%-ra csökkent. Mindezen változások mellett 2019-ről 2020-ra csökkent mind a perinatalis mortalitás (6,3‰-ről 4,2‰-re), mind a szülés után a Neonatalis Intenzív Centrumba történő felvételek aránya (14,8%-ról 13,5%-ra). Következtetések: A bemutatott tényezők együttes hatásaként - elsődlegesen a megfelelő és következetesen betartott protokolloknak köszönhetően - a szülésindukciók aránya és sikeressége jelentősen növekedett, a császármetszések aránya szignifikánsan csökkent, javuló perinatalis morbiditási és mortalitási mutatók mellett. Orv Hetil. 2021; 162(21): 811-823. SUMMARY INTRODUCTION The pandemic caused by the new coronavirus (SARS-CoV-2) has catalized several changes in many fields of our lives, and also at the Department of Obstetrics and Gynecology of the University of Debrecen, Hungary. OBJECTIVES We wanted to analyse the compound effect of our new local protocols regarding elective labour inductions at term, the coronavirus pandemic and the resulting infection control measures, the merging of the Obstetrics and Gynecology Ward of the Kenézy County Hospital of Debrecen and the University Department of Obstetrics and Gynecology, and also the change of the legal environment. METHODS Local protocols were introduced: 1. Labour induction. 2. Cervical ripening in labour induction. 3. Choosing the route of delivery after cesarean. 4. Management of pregnancy around term in the case of planned trial of labour after cesarean. We compared the obstetrical data (number of deliveries, cesarean section rate, perinatal outcome and the rate and success rate of labour inductions) before and after the implementation of the protocols. The results were also compared to the Hungarian national database. RESULTS The annual cesarean rate at our department dropped to 33.5% in 2020. In the first 9-month period, after the introduction of the new reforms, the cesarean rate decreased to 30.7%, whereas the Hungarian national rate was 40.3% in 2020. At our department, 20% of all the deliveries were induced and 74% of them led to vaginal deliveries in 2020, while in 2019 only 11% of deliveries were labour inductions, and 47% of these cases were vaginal deliveries. The monthly number of deliveries was rising constantly between January 2020 (250 deliveries) and January 2021 (450 deliveries), and the monthly cesarean rate decreased from 41% to 25%. Comparing the data of 2019 and 2020, the annual perinatal mortality rate dropped from 6.3‰ in 2019 to 4.2‰ in 2020. Neonatal morbidity, as measured by admissions to the neonatal intensive care unit, also decreased (14.8% in 2019 and 13.5% in 2020). CONCLUSIONS As a compound result of the described factors, but mainly due to the new protocols, both the rate and the success rate of labour inductions increased significantly, while the cesarean rate decreased with improving perinatal mortality and morbidity. Orv Hetil. 2021; 162(21): 811-823.
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Affiliation(s)
- Tamás Deli
- 1 Debreceni Egyetem, Általános Orvostudományi Kar, Szülészeti és Nőgyógyászati Intézet, Debrecen, Nagyerdei krt. 98., 4032
| | - Rudolf Lampé
- 1 Debreceni Egyetem, Általános Orvostudományi Kar, Szülészeti és Nőgyógyászati Intézet, Debrecen, Nagyerdei krt. 98., 4032
| | - Alpár Gábor Juhász
- 1 Debreceni Egyetem, Általános Orvostudományi Kar, Szülészeti és Nőgyógyászati Intézet, Debrecen, Nagyerdei krt. 98., 4032
| | - Tamás Kovács
- 1 Debreceni Egyetem, Általános Orvostudományi Kar, Szülészeti és Nőgyógyászati Intézet, Debrecen, Nagyerdei krt. 98., 4032
| | - Péter Daragó
- 1 Debreceni Egyetem, Általános Orvostudományi Kar, Szülészeti és Nőgyógyászati Intézet, Debrecen, Nagyerdei krt. 98., 4032
| | - György Bacskó
- 1 Debreceni Egyetem, Általános Orvostudományi Kar, Szülészeti és Nőgyógyászati Intézet, Debrecen, Nagyerdei krt. 98., 4032
| | - Olga Török
- 1 Debreceni Egyetem, Általános Orvostudományi Kar, Szülészeti és Nőgyógyászati Intézet, Debrecen, Nagyerdei krt. 98., 4032
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Fishel Bartal M, Sibai BM, Ilan H, Fried M, Rahav R, Alexandroni H, Schushan Eisan I, Hendler I. Trial of labor after cesarean (TOLAC) in women with premature rupture of membranes . J Matern Fetal Neonatal Med 2019; 33:2976-2982. [PMID: 30652525 DOI: 10.1080/14767058.2019.1566312] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: The aim of this study was to assess the success rate of a trial of labor after a previous cesarean section (TOLAC) in the settings of premature rupture of membranes (PROM) and to compare conservative management with spontaneous labor and induction of labor.Methods: This was a retrospective cohort study conducted in a single tertiary care center between January 2011 and March 2017. Women with singleton pregnancy and a previous cesarean section (CS) who presented with PROM and underwent TOLAC were included. Outcomes and rate of successful vaginal delivery after induction of labor were compared to conservative treatment and spontaneous labor.Results: Among 830 women who met the inclusion criteria, 723 (87.1%) had a spontaneous onset of labor following PROM and 107 (12.9%) had an induction of labor. The rate of successful TOLAC was similar between the groups (75.7 vs. 81.6%, respectively, p = .22). However, induction of labor was associated with an increased risk for uterine rupture (1.87 vs. 0.96%, p < .001), operative complications (6.7 vs. 2.3%, p < .001), and composite maternal postpartum complications (21.4 vs. 10.7%, respectively, p = .014) compared to conservative management with spontaneous initiation of labor. There was no difference in neonatal outcome between the groups.Conclusion: Induction of labor following PROM in women with a previous CS is associated with high successful vaginal delivery rate. However, the risk for uterine rupture and operative and maternal complications is significantly increased compared to spontaneous initiation of labor.
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Affiliation(s)
- Michal Fishel Bartal
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Baha M Sibai
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal Fetal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UT Health), Houston, TX, USA
| | - Hadas Ilan
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moran Fried
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roni Rahav
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Heli Alexandroni
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Irit Schushan Eisan
- Department of Neonatology, The Edmond and Lily Safra Children's Hospital and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Israel Hendler
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Maier JT, Metz M, Watermann N, Li L, Schalinski E, Gauger U, Rath W, Hellmeyer L. Induction of labor in patients with an unfavorable cervix after a cesarean using an osmotic dilator versus vaginal prostaglandin. J Perinat Med 2018; 46:299-307. [PMID: 28672756 DOI: 10.1515/jpm-2017-0029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 05/11/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Trial of labor after cesarean (TOLAC) is a viable option for safe delivery. In some cases cervical ripening and subsequent labor induction is necessary. However, the commonly used prostaglandins are not licensed in this subgroup of patients and are associated with an increased risk of uterine rupture. METHODS This cohort study compares maternal and neonatal outcomes of TOLAC in women (n=82) requiring cervical ripening agents (osmotic dilator vs. prostaglandins). The initial Bishop scores (BSs) were 2 (0-5) and 3 (0-5) (osmotic dilator and prostaglandin group, respectively). In this retrospective analysis, Fisher's exact test, the Kruskal-Wallis rank sum test and Pearson's chi-squared test were utilized. RESULTS Vaginal birth rate (including operative delivery) was 55% (18/33) in the osmotic dilator group vs. 51% (25/49) in the dinoprostone group (P 0.886). Between 97% and 92% (32/33 and 45/49) (100%, 100%) of neonates had an Apgar score of >8 after 1 min (5, 10 min, respectively). The time between administration of the agent and onset of labor was 36 and 17.1 h (mean, Dilapan-S® group, dinoprostone group, respectively). Time from onset of labor to delivery was similar in both groups with 4.4 and 4.9 h (mean, Dilapan-S® group, dinoprostone group, respectively). Patients receiving cervical ripening with Dilapan-S® required oxytocin in 97% (32/33) of cases. Some patients presented with spontaneous onset of labor, mostly in the dinoprostone group (24/49, 49%). Amniotomy was performed in 64% and 49% (21/33 and 24/49) of cases (Dilapan-S® group and dinoprostone group, respectively). CONCLUSIONS This pilot study examines the application of an osmotic dilator for cervical ripening to promote vaginal delivery in women who previously delivered via cesarean section. In our experience, the osmotic dilator gives obstetricians a chance to perform induction of labor in these women.
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Affiliation(s)
- Josefine T Maier
- Department of Obstetrics and Gynecology, Vivantes Klinikum im Friedrichshain, Affiliate of Charité University, Berlin, Germany
| | - Melanie Metz
- Department of Obstetrics and Gynecology, Vivantes Klinikum im Friedrichshain, Affiliate of Charité University, Berlin, Germany
| | - Nina Watermann
- Department of Obstetrics and Gynecology, Vivantes Klinikum im Friedrichshain, Affiliate of Charité University, Berlin, Germany
| | - Linna Li
- Department of Obstetrics and Gynecology, Vivantes Klinikum im Friedrichshain, Affiliate of Charité University, Berlin, Germany
| | - Elisabeth Schalinski
- Department of Obstetrics and Gynecology, Vivantes Klinikum im Friedrichshain, Affiliate of Charité University, Berlin, Germany
| | | | - Werner Rath
- Department of Obstetrics and Gynecology, University of Aachen, Aachen, Germany
| | - Lars Hellmeyer
- Department of Obstetrics and Gynecology, Vivantes Klinikum im Friedrichshain, Affiliate of Charité University, Berlin, Germany
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Thornton P. Limitations of Vaginal Birth After Cesarean Success Prediction. J Midwifery Womens Health 2018; 63:115-120. [PMID: 29356333 DOI: 10.1111/jmwh.12724] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 12/02/2017] [Accepted: 12/04/2017] [Indexed: 11/27/2022]
Abstract
The Society for Maternal-Fetal Medicine endorses an algorithm for estimating the probability of successful vaginal birth for women undergoing trial of labor after cesarean (TOLAC). The algorithm is available online in the form of an easy-to-use calculator. This calculator has significant limitations that are easily overlooked by women and providers alike. The calculator has much greater positive than negative predictive power, and it cannot predict unsuccessful TOLAC or uterine rupture. Furthermore, the calculator cannot predict rare catastrophes, such as unplanned hysterectomy, permanent injury, or death. Predictions are heavily influenced by race and ethnicity, which are social and not biological constructs. Relevant variables, such as provider attitudes and institutional differences, are not accounted for. Providers should be mindful and transparent about calculator limitations when counseling women, particularly Latina and African American women. It may be appropriate to use the calculator to inform but not restrict women's options.
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White HK, le May A, Cluett ER. Evaluating a Midwife-Led Model of Antenatal Care for Women with a Previous Cesarean Section: A Retrospective, Comparative Cohort Study. Birth 2016; 43:200-8. [PMID: 26991669 DOI: 10.1111/birt.12229] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Research is yet to identify effective and safe interventions to increase the vaginal birth after cesarean (VBAC) rate. This research aimed to compare intended and actual VBAC rates before and after implementation of midwife-led antenatal care for women with one previous cesarean birth and no other risk factors in a large, tertiary maternity hospital in England. METHODS This was a retrospective, comparative cohort study. Data were collected from the medical records of women with one previous lower segment cesarean delivery and no other obstetric, medical, or psychological complications who gave birth at the hospital before (2008) and after (2011) the implementation of midwife-led antenatal care. Chi-squared analysis was used to calculate the odds ratio, and logistic regression to account for confounders. RESULTS Intended and actual VBAC rates were higher in 2011 compared with 2008: 90 percent vs. 77 percent, adjusted odds ratio (aOR) 2.69 (1.48-4.87); and 61 percent vs. 47 percent, aOR 1.79 (1.17-2.75), respectively. Mean rates of unscheduled antenatal care sought via the delivery suite and inpatient admissions were lower in 2011 than 2008. Postnatal maternal and neonatal safety outcomes were similar between the two groups, except mean postnatal length of stay, which was shorter in 2011 compared with 2008 (2.67 vs. 3.15 days). CONCLUSIONS Implementation of midwife-led antenatal care for women with one previous cesarean offers a safe and effective alternative to traditional obstetrician-led antenatal care, and is associated with increased rates of intended and actual VBAC.
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Abstract
BACKGROUND High rates of primary cesarean internationally continue to create decision dilemmas for women and practitioners about birth in subsequent pregnancies. This article explores values and expectations that guide women during decision making about the next birth after cesarean and identifies factors that influence consistency between women's choices and actual birth experiences. METHODS Narrative analysis was used to identify key themes in decision-making experiences of women who were facing a choice about mode of birth after cesarean. A sample of 187 women provided qualitative data about their choices for birth at 36-38 weeks. At 6-8 weeks after the birth, 168 also wrote about their experiences of birth and the process of making the decision. RESULTS Decision making about birth after cesarean was complex and difficult for many women; strong emotions were expressed as they weighed birth options. Fear and anxiety were articulated as women explained their choices and expectations. Avoidance of the previous cesarean experience, an expectation of a "better" or "faster" recovery, and issues around "safety" for the baby were common reasons given for wanting either vaginal or cesarean birth. Practitioner preferences were influential and women's need for information about their options underpinned their confidence or certainty about their decision. CONCLUSIONS Strategies are needed to support practitioners to expand discussions beyond clinical algorithms about physical risks and benefits of birth options and to actively integrate women's values and preferences into decisions about birth.
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Affiliation(s)
- Allison Shorten
- Yale University School of Nursing, West Haven, Connecticut, USA
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Abstract
In this column, the author summarizes research studies relevant to normal birth. The studies summarized include a large trial evaluating the effect of prior vaginal births after a cesarean on outcomes in subsequent births; a study linking umbilical cord blood pH with intellectual outcomes in childhood; and a prospective trial evaluating the effect of routine antenatal nonstress testing on maternal anxiety. The author also highlights four articles about normal birth in a recent nursing journal series dedicated to the topic.
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Affiliation(s)
- Amy M Romano
- AMY ROMANO is a midwife, author, and advocate for mother-friendly maternity care. She has provided research and advocacy support to the Lamaze Institute for Normal Birth since 2004 and now works as a home- and hospital-based midwife in Connecticut
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Goer H, Sagady Leslie M, Romano A. Step 6: does not routinely employ practices, procedures unsupported by scientific evidence: the coalition for improving maternity services:. J Perinat Educ 2007; 16 Suppl 1:32S-64S. [PMID: 18523680 PMCID: PMC2409136 DOI: 10.1624/105812407x173182] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Step 6 of the Ten Steps of Mother-Friendly Care addresses two issues: 1) the routine use of interventions (shaving, enemas, intravenous drips, withholding food and fluids, early rupture of membranes, and continuous electronic fetal monitoring; and 2) the optimal rates of induction, episiotomy, cesareans, and vaginal births after cesarean. Rationales for compliance and systematic reviews are presented.
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Key Words
- NPO, labor
- VBAC and induction of labor
- VBAC rates
- amniotomy artificial rupture of membranes
- anal incontinence
- cesarean
- cesarean rate
- cesarean, adverse effects
- elective induction
- elective repeat cesarean
- electronic fetal monitoring
- enema, labor
- episiotomy rate
- episiotomy, adverse effects
- episiotomy, median
- episiotomy, mediolateral
- induction and adverse effects
- intrapartum cardiotocography
- intravenous drip, adverse effects
- intravenous drip, labor
- intravenous nutrition, labor
- labor induced
- labor induction
- labor preparation
- maternal satisfaction and induction
- nutrition, labor
- obstetric birth, adverse effects
- obstetric procedures, adverse effects
- oral intake, labor
- pelvic-floor dysfunction
- perineal shaving, labor
- rates of induction
- spontaneous labor rates
- urinary incontinence
- vaginal birth after cesarean (VBAC)
- vaginal birth, adverse effects
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