Intrapartum Interventions Research Articles

Are rates of clinical interventions during pregnancy and childbirth different for refugees and asylum seekers in high-income countries? A scoping review.

Adequate maternity care and appropriate clinical interventions during labour and delivery can reduce adverse perinatal outcomes, but unnecessary interventions may cause harm. While studies have shown that refugees and asylum seekers face important barriers when accessing maternity care, there is a lack of high-quality quantitative data on perinatal health interventions, such as induction of labour or caesarean sections, among refugees and asylum seekers and the findings reported in the literature tend to be inconsistent. Our goal was to examine and synthesise the evidence regarding the rates of intrapartum clinical interventions in women who are refugees and asylum seekers in high-income countries compared to other population groups. We conducted a scoping review of peer-reviewed studies published in English since 2011 that report original quantitative findings regarding intrapartum clinical interventions among refugees and asylum seekers in high-income countries compared to those in non refugee, non asylum seeker populations. We examined reported rates of clinical pain relief, labour induction and augmentation, episiotomies, instrumental deliveries, and caesarean sections. Twenty-five papers were included in the review. Findings indicate that refugees and asylum seekers were less likely to receive pain relief, with 16 out of 20 data points showing unadjusted ORs ranging from 0.20 (CI: 0.10-0.60) to 0.96 (CI: 0.70-1.32). Similarly, findings indicate lower odds of instrumental delivery among refugees and asylum seekers with 14 of 21 data points showing unadjusted ORs between 0.25 (CI: 0.15-0.39) and 0.78 (CI: 0.47-1.30); the remaining papers report no statistically significant difference between groups. There was no discernable trend in rates of labour induction and episiotomies across studies. The studies included in this review suggest that asylum seekers and refugees are less likely to receive clinical pain relief and experience instrumental delivery than non-refugee groups in high-income countries. This review strengthens our understanding of the links between immigration status and maternity care, ultimately informing policy and practice to improve perinatal health and the provision of care for all.

Predictors of a positive birth experience in childbirth: A cross-sectional study

BackgroundRecognizing predictors of positive birth experience is viewed as essential for minimizing negative experiences during childbirth that are related to current obstetric care, especially when those could be attributed to intrapartum interventions. The CEQ-E is a suitable instrument for investigating maternal birth experience within the Spanish population, highlighting the necessity to identify predictors for all its domains. This study aimed to identify predictors of positive birth experience based on socio-demographic and clinical variables, and obstetric interventions. MethodsCross-sectional study conducted with consecutive sampling (N = 301). Quantitative data were collected by the Childbirth Experience Questionnaire (CEQ-E) and an Ad hoc questionnaire. Clinical data was obtained from participants' medical records. Descriptive, bivariant and multivariant analysis were performed. ResultsThe CEQ overall mean score was 3.18(SD:0.42), showing the highest score for the professional support (3.79; SD: 0.43) and the lowest for the own capacity (2.8; SD:0.57). All domains and overall score showed negative correlations with the number of intrapartum interventions (p ≤ .001). Inductions of labour, instrumental deliveries, and caesarean sections were inversely related to; overall birth experience score (p ≤ .001), perceived safety (p ≤ .001), and own capacity (p ≤ .001). Epidural analgesia was linked to worse values of birth experience (p ≤ .001). Predictors of positive birth experience were identified as having a midwife as birth attendant (p ≤ .001) and neonatal higher Apgar scores at birth (p ≤ .001), whereas higher maternal education grade (p = .04), inductions of labour (p ≤ .001) and caesarean births (p ≤ .001) had worse values on birth experience. ConclusionWomen reported a positive birth experience, and professional support was highly valued. Key predictors of lower scores in birth experience included higher maternal education, caesarean and instrumental deliveries, and neonatal intensive care unit (NICU) admission. Spontaneous labour onset predicted better capacity and safety. Epidural use decreased participation. Midwife-attended births reported better scores on birth experience, highlighting their importance in maternal care.

Impact of intrapartum quality improvement interventions on stillbirths and other adverse pregnancy outcomes: A protocol for systematic review and meta-analysis.

Stillbirths are a major global health concern. Half of stillbirths occur during intrapartum period, mostly in low- and middle-income countries of sub-Saharan Africa and South Asia. Achieving a stillbirth rate of less than 12 per 1000 births by 2030 is the global target of Every Newborn Action Plan and Sustainable Development Goals. Evidence suggests that improving intrapartum quality of care can help reduce stillbirths and other adverse pregnancy outcomes. This study will explore whether quality improvement (QI) packages at intrapartum care points can reduce stillbirths and other outcomes such as maternal and neonatal mortality. We will conduct a systematic literature review and meta-analysis. Comprehensive search strategy will be developed for databases PubMed, Web of Science, ScienceDirect, ProQuest, Cochrane and China National Knowledge Infrastructure. We will include randomized controlled trials, controlled non-randomized trials, controlled clinical trials, interrupted time series, cohort studies, case-control and nested case-control studies which assess the impact of QI interventions at intrapartum points of care on stillbirths and other adverse pregnancy outcomes. We will search grey literature such as unpublished research studies, dissertations and unfinished trials. English and non-English language articles will be included to avoid language bias. We will also evaluate reporting quality and risk of bias. Sensitivity tests will be carried out for heterogeneity. Pooled estimates of effect sizes will be computed with random-effects models. Supplementation of the quantitative synthesis with a qualitative narrative synthesis would be added, if deemed necessary. We will explore publication bias using funnel plot and Egger's regression test will be used for evaluation, if needed. We will report pooled effectiveness of different intrapartum QI interventions across multiple settings in averting stillbirths and other adverse outcomes such as maternal mortality and neonatal mortality.

Outcomes associated with planned place of birth among low-risk pregnancies in Ontario, Canada (2012-2021): A protocol for a population-based propensity score weighted cohort study.

Evidence suggests that for low-risk pregnancies, planned home births attended by a skilled health professional in settings where such services are well integrated are associated with lower risk of intrapartum interventions and no increase in adverse health outcomes. Monitoring and updating evidence on the safety of planned home births is necessary to inform ongoing clinical and policy decisions. This protocol describes a population-based retrospective cohort study which aims to compare risk of (a) neonatal morbidity and mortality, and (b) maternal outcomes and birth interventions, between people at low obstetrical risk with a planned home birth with a midwife, a planned a hospital birth with a midwife, or a planned hospital birth with a physician. The study population will include Ontario residents who gave birth in Ontario, Canada between April 1, 2012, and March 31, 2021. We will use data collected prospectively in a provincial perinatal data registry. The primary outcome will be severe neonatal morbidity or mortality, a composite binary outcome that includes one or more of the following conditions: stillbirth during the intrapartum period, neonatal death (death of a liveborn infant in the first 28 completed days of life), five-minute Apgar score <4, or infant resuscitation requiring cardiac compressions. We will conduct a stratified analysis with three strata: nulliparous, parous-no previous caesarean birth, and parous-prior caesarean birth. To reduce the impact of selection bias in estimating the effect of planned place of birth on neonatal and maternal outcomes, we will use propensity score (PS) overlap weighting (OW) and modified Poisson regression to conduct multivariate analyses.

Evidence-based intrapartum care during vaginal births: Direct observations in a tertiary care hospital in Central Sri Lanka

BackgroundEvidence-based practice (EBP) is an effective approach to improve maternal and newborn outcomes at birth. ObjectiveThis study aimed to assess the current intrapartum practices of a tertiary care hospital in Central Province, Sri Lanka, during vaginal births. The benchmark for this assessment was the World Health Organisation's (WHO) recommendations on intrapartum care for a positive childbirth experience. MethodsAn observational study was conducted at the delivery room of Teaching Hospital, Peradeniya with the participation of 196 labouring women who were selected using systematic random sampling. A non-participant observation checklist covering labour room admission procedures, management of the first, second, and third stages of labour, and immediate care of the newborn and postpartum mother was used for the data collection. The care interventions implemented throughout labour and childbirth were observed and recorded. The data analysis was done using SPSS version 22. ResultsWHO-recommended practices such as providing privacy (33.2%), offering oral fluids (39.3%), and opioids for pain relief (48.5%) were found to be infrequent. Encouraging correct pushing techniques (77.6%), early breastfeeding (83.2%), regular assessment of vaginal bleeding (91.3%), skin-to-skin contact (93.4%), and using prophylactic uterotonics (100.0%) were found to be frequent. However, labour companionship, use of upright positions during labour, women's choice of birth position, and use of manual or relaxation techniques for pain relief were not observed in hospital intrapartum care. ConclusionThe findings of the study indicate that additional attention and monitoring are required to align the current intrapartum care practices with the WHO recommendations. Moreover, the adoption of evidence-based intrapartum care should be encouraged by conveying the standard evidence-based intrapartum care guidelines to the grassroots level healthcare workers to avoid intrapartum interventions.

Clinical Trials That Have Changed Clinical Practice and Care of Pregnant People With HIV.

Over the last 4 decades, significant advances in the care of HIV during pregnancy have successfully reduced, and nearly eliminated, the risk of perinatal HIV transmission. The baseline risk of transmission without intervention (25% to 30%) is now <1% to 2% in the United States with contemporary antepartum, intrapartum, and postnatal interventions. In this review, we discuss 3 landmark clinical trials that substantially altered obstetric practice for pregnant individuals with HIV and contributed to this extraordinary achievement: 1) the Pediatric AIDS Clinical Trials Group 076 Trial determined that antepartum and intrapartum administration of antiretroviral drug zidovudine to the pregnant individual, and postnatally to the newborn, could reduce the risk of perinatal transmission by approximately two-thirds; 2) the European Mode of Delivery Collaboration Trial demonstrated performance of a prelabor cesarean birth before rupture of membranes among pregnant people with viremia reduced the risk of perinatal transmission compared with vaginal birth; and 3) the International Maternal Pediatric Adolescent AIDS Clinical Trials Network 2010 Trial identified that dolutegravir-containing, compared with efavirenz-containing, antiretroviral regimens during pregnancy achieved a significantly higher rate of viral suppression at delivery with shorter time to viral suppression, with fewer adverse pregnancy outcomes. Collectively, these trials not only advanced obstetric practice but also advanced scientific understanding of the timing, mechanisms, and determinants of perinatal HIV transmission. For each trial, we will describe key aspects of the study protocol and outcomes, insights gleaned about the dynamics of perinatal transmission, how each study changed clinical practice, and relevant updates to current practice since the trial's publication.

The current status of Group B Streptococcus infection in the reproductive tract of late-pregnancy women and its impact on pregnancy outcomes.

Analyze Group B Streptococcus (GBS) infection in late-pregnancy pregnant women in Shanghai, the risk factors of GBS infection, and its impact on pregnancy outcomes, providing guidance for early prevention and treatment in clinical practice. We selected 12,132 late-pregnancy pregnant women admitted from January 2022 to December 2022 as the research subjects. Based on the GBS test results of reproductive tract secretion samples from pregnant women, 210 cases of GBS positive pregnant women were randomly selected as the observation group, and 200 cases of GBS negative pregnant women were selected as the control group. The risk factors of infection and the impact on pregnancy outcomes were compared between the two groups. The GBS colonization rate of pregnant women in this study was 6.52%; the incidence of Vaginal delivery and Neonatal infection in GBS positive group was significantly higher than that in GBS negative group (P < 0.05); with Neonatal infection as the dependent variable, and the GBS infection, Vaginal delivery and GDM of the elderly and women in late pregnancy as independent variables, the results showed that GBS infection of women in late pregnancy was an independent risk factor for Neonatal infection. Clinical practice should attach great importance to GBS infection in late pregnancy, strengthen GBS screening in late pregnancy, and actively implement the strategy of intrapartum antibiotic intervention (IAP), which is of great significance in reducing the vertical infection rate of maternal and infant GBS and improving the quality of newborn birth.

Determining the Impact of Cervical Dilation at Admission on Intrapartum Interventions and Labor Satisfaction in Pregnant Women

Determining the Impact of Cervical Dilation at Admission on Intrapartum Interventions and Labor Satisfaction in Pregnant Women

Normal value and changes in CRP values on maternal and fetal umbilical cord blood with the labor and intrapartum interventions

Introduction: C-reactive protein (CRP) is widely used as an inflammatory marker. Since labour is an inflammatory process, CRP values vary during the intrapartum and postpartum period due to multiple factors.Methods: A descriptive-analytical study was carried out at Castle Street Hospital for Women. Mothers who have term singleton pregnancies with uneventful antenatal periods and have undergone vaginal delivery were recruited for the study. Samples were obtained just after admission to the labour ward (S1), 24 hours after the delivery (S2), and the fetal umbilical cord blood (S3). Reference ranges for S2 and S3 were determined using the interquartile range (IQR).Results: Out of 300 mothers recruited for the study, the mean age was 26.73 years (95% Confidence interval 19.5-36.9). There were 266 samples of S1,177 samples of S2, and 173 samples of S3 were collected. The reference range for S2 is 12.70-150.83 mg/dl, and for S3 is 0.1-8.1 mg/dL. The S2 value is significantly associated with duration of labor (r=0.47, p=0.046), number of vaginal examinations (VEs) (p &lt; 0.001), augmentation of labor (AOL) (p=0.001), method of cervical ripening (p=0.014) and intrapartum intervention (p &lt; 0.001). The number of vaginal examinations (p=0.02) and augmentation of labor (p=0.025) are significantly associated with fetal umbilical cord blood (S3).Conclusion: Early postpartum CRP can be risen up to 151 mg/dL after 24 hours of vaginal delivery. It may be associated with prolonged labor, number of VEs performed, AOL, method of cervical ripening, and episiotomy. Fluctuation of normal CRP values during the periods of antenatal, intrapartum, and postpartum needs to be assessed in the Sri Lankan community.

The impact of body mass index on labour management and mode of delivery: A retrospective matched cohort study.

This study aims to examine the association between body mass index (BMI) and mode of delivery, progression of labour, and intrapartum interventions. This was a retrospective matched cohort study including Class III obese (BMI ≥40 kg/m2) and normal BMI (BMI <25 kg/m2) women planning a vaginal birth who had a live, singleton delivery from January 2015 to December 2018. Patients were matched (1:1) based on age, gestational age, parity, onset of labour and birth weight. The primary outcome was caesarean delivery (CD). Secondary outcomes were delivery outcomes, intrapartum management and interventions. Rates of each outcome were compared with matched analysis, and duration of labour with time-to-event analysis. We studied two groups of 300 pregnant women. The CD rate was significantly higher for obese women than the normal BMI cohort (19.3% vs 13.3%; risk ratio (RR) 1.43, 95% CI 1.02-1.98, P = 0.035). Cervical dilation prior to CD for failure to progress was slower in obese than normal BMI (0.04 vs 0.16 cm/h). The obese cohort had a longer duration of labour in those who underwent induction (13.70 vs 11.48 h, P = 0.024). Intrapartum intervention rates were higher for obese women, with significant differences in rates of fetal scalp electrodes (72.7% vs 22.7%, RR 3.20, 95% CI 2.58-3.99, P < 0.001), intrauterine pressure catheters (18.3% vs 0%, P < 0.001), epidural analgesia (44.0% vs 37.0%, RR 1.20, 95% CI 1.01-1.44, P = 0.040) and fetal scalp lactate sampling (8.0% vs 3.0%, RR = 2.67, 95% CI 1.33-5.33, P = 0.004). Class III obesity is associated with an increased risk of CD and intrapartum interventions.

Implementation of normal childbirth guidelines among midwives: Adherence and influencing factors

BackgroundClinical practice guidelines on normal childbirth were issued worldwide with a view to achieve evidence-based, cost-effective and universal intrapartum care. Effective implementation of guideline recommendations is impossible without a full evaluation and understanding of current practice and factors influencing adherence among midwives. AimThis study aimed to explore midwives’ adherence to clinical practice guidelines on normal childbirth and factors influencing the implementation of guideline recommendations in mainland China. DesignWe used a mixed-method sequential explanatory design. MethodsA national level cross-sectional survey was conducted among 718 midwives to investigate their adherence to guideline recommendations on normal childbirth. Based on the findings of quantitative study phase, we developed the interview outline and performed semi-structured interviews with thirteen midwives to explore potential factors influencing their implementation of normal childbirth guidelines. An inductive thematic analysis was undertaken to identify themes, which were then deductively mapped to the Theoretical Domains Framework (TDF). ResultsMidwives’ adherence to the guideline recommendations was relatively low, with non-adherence to thirteen guideline recommendations (41.94%) being observed. Six domains on the TDF and one additional theme were found to be factors influencing midwives’ implementation of guideline recommendations on normal childbirth, with behavioural regulation, beliefs about consequences, professional roles and responsibilities being identified as barriers for interventions recommended against use, knowledge, environmental context and resources being identified as enablers for interventions recommended for use, and skills and women’s preference being identified as barriers/enabler for both. ConclusionGuideline adherence can be improved by multifaceted efforts at professional, organizational and maternal levels. The identification of barriers and enablers of guideline implementation provides a solid foundation for further reducing non-evidence-based intrapartum interventions.

Antenatal, Intrapartum and Postpartum Interventions for Preventing Postpartum Urinary and Faecal Incontinence: An Umbrella Overview of Cochrane Systematic Reviews.

Post-partum, women can suffer from urinary and faecal incontinence. It is important to assess interventions to prevent this problem. Cochrane systematic reviews summarize the data available from systematic reviews of randomized trials assessing interventions. We conducted an umbrella overview of Cochrane systematic reviews encompassing antenatal, intrapartum and postpartum interventions for preventing postpartum urinary and faecal incontinence. We searched the Cochrane Database of Systematic Reviews on the 9 May 2023. Results: Our search identified nine Cochrane reviews providing results. Data for urinary and faecal incontinence were available from 77 (72%) trials and included 51,113 women. The reviews assessed antenatal digital perineal massage, pelvic floor muscle training, techniques for repairing anal sphincter tears, routine use of episiotomy, use of endoanal ultrasound prior to repairing perineal tears, caesarean versus vaginal delivery (overall, for breech and for twins), and vaginal delivery with forceps or vacuum. Only the use of a vacuum instead of forceps if an assisted vaginal delivery is needed, the use of an endo-anal ultrasound prior to repairing perineal tears and postpartum pelvic floor muscle training suggest a reduction in postpartum incontinence. Due to the small number of relevant reviews, a consequence of the relatively small number of primary studies, the effect of almost all the tested interventions was found to be imprecise.

New labor management and obstetric outcomes: A systematic review and meta-analysis

Objective: This systematic review and meta-analysis is to compare the new labor management guideline with the traditional WHO guideline with regard to obstetric outcomes. Methods: The literature search was performed in the following databases: PubMed, Embase, Web of Science, the Cochrane Library and Chinese databases (including CNKI, WanFang Database and VIP). Randomized controlled trials (RCTs) or cohort studies comparing the new labor management and the old WHO guideline in terms of maternal and neonatal morbidity in low-risk pregnant women were included. Study quality was assessed using the Cochrane Risk Bias Evaluation Tool and Newcastle-Ottawa Scale (NOS). The I2 statistic was used to evaluate heterogeneity. We used the random-effects model to pool the relative risk (RR) with corresponding 95% confidence intervals (CI). Prespecified subgroup and sensitivity analyses were conducted to explore the potential influencing factors. Publication bias analysis was also assessed based on funnel plots. Results: A total of 45 studies with a total sample size of 82,016 women were eventually included, with 15 RCTs and 30 cohort studies. 44 studies were included for data synthesis. Women with new labor management had less labor augmentation with oxytocin (RCTs: RR = 0.55 [0.36, 0.83], I2 = 47%; cohort studies: RR = 0.62 [0.55, 0.70], I2 = 58%), intrapartum cesarean section (RCTs: RR = 0.52 [0.47, 0.59], I2 = 0; cohort studies: RR = 0.61 [0.55, 0.67], I2= 75%) and operative vaginal delivery (RCTs: RR = 0.60 [0.42, 0.87], I2 = 0; cohort studies: RR = 0.69 [0.55, 0.86], I2 = 82%) without increasing the incidence of 3rd- and 4th-degree perineal laceration, postpartum hemorrhage, infectious morbidity and postpartum urine retention, fetal distress, neonatal asphyxia or neonatal intensive care unit (NICU) admission. These results were robust to sensitivity analyses. Conclusion: Our study indicates that the new labor management guideline may be more beneficial than the traditional WHO guideline, with fewer intrapartum interventions and no increase in adverse obstetric outcomes.

Cost analysis of an intrapartum quality improvement package for improving preterm survival and reinforcing best practices in Kenya and Uganda.

Preterm birth is a leading cause of under-5 mortality, with the greatest burden in lower-resource settings. Strategies to improve preterm survival have been tested, but strategy costs are less understood. We estimate costs of a highly effective Preterm Birth Initiative (PTBi) intrapartum intervention package (data strengthening, WHO Safe Childbirth Checklist, simulation and team training, quality improvement collaboratives) and active control (data strengthening, Safe Childbirth Checklist). In our analysis, we estimated costs incremental to current cost of intrapartum care (in 2020 $US) for the PTBi intervention package and active control in Kenya and Uganda. We costed the intervention package and control in two scenarios: 1) non-research implementation costs as observed in the PTBi study (Scenario 1, mix of public and private inputs), and 2) hypothetical costs for a model of implementation into Ministry of Health programming (Scenario 2, mostly public inputs). Using a healthcare system perspective, we employed micro-costing of personnel, supplies, physical space, and travel, including 3 sequential phases: program planning/adaptation (9 months); high-intensity implementation (15 months); lower-intensity maintenance (annual). One-way sensitivity analyses explored the effects of uncertainty in Scenario 2. Scenario 1 PTBi package total costs were $1.11M in Kenya ($48.13/birth) and $0.74M in Uganda ($17.19/birtth). Scenario 2 total costs were $0.86M in Kenya ($23.91/birth) and $0.28M in Uganda ($5.47/birth); annual maintenance phase costs per birth were $16.36 in Kenya and $3.47 in Uganda. In each scenario and country, personnel made up at least 72% of total PTBi package costs. Total Scenario 2 costs in Uganda were consistently one-third those of Kenya, largely driven by differences in facility delivery volume and personnel salaries. If taken up and implemented, the PTBi package has the potential to save preterm lives, with potential steady-state (maintenance) costs that would be roughly 5-15% of total per-birth healthcare costs in Uganda and Kenya.

Effect of Calcium Channel Blocker on Labor Curve in Pregnant Individuals with Chronic Hypertension.

This study aimed to compare the labor progress between individuals who received calcium channel blocker (CCB) and those who did not receive CCB during labor. This was a secondary analysis of a retrospective cohort study of individuals with chronic hypertension who underwent vaginal delivery at a tertiary care center from January 2010 to December 2020. We excluded individuals with prior uterine surgeries and a 5-minute Apgar score of less than 5. We used a repeated-measures regression with a third-order polynomial function to compare the average labor curves according to antihypertensive medication. Estimates of the median (5th-95th percentile) traverse times between two dilations were computed using interval-censored regression. Of 285 individuals with chronic hypertension, 88 (30.9%) received CCB. Individuals who received CCB during labor compared with those who did not were more likely to deliver at earlier gestational age and to have pregestational diabetes and superimposed preeclampsia (p < 0.01). The progress of labor in the latent phase was not found to be significantly different between both groups (median: 11.51 vs. 8.74 hours; p = 0.08). However, after stratification by parity, nulliparous individuals who received CCB during labor were more likely to have a longer latent phase of labor (median: 14.4 vs. 8.5 hours; p = 0.03) CONCLUSION: A calcium channel blocker may slow the latent phase of labor in individuals with chronic hypertension. Aiming to minimize intrapartum iatrogenic interventions, allowing adequate time for pregnant individuals during the latent phase of labor is especially important if individuals are on a calcium channel blocker. · Calcium channel blockers seem to be associated with a longer latent phase of labor.. · The effect of calcium channel blocker on labor was not observed in multiparous individuals.. · Allowing adequate labor time for individuals taking calcium channel blocker is important..

Women’s and midwives’ views on the optimum process for informed consent for research in a feasibility study involving an intrapartum intervention: a qualitative study

BackgroundRecruitment to intrapartum research is complex. Women are expected to understand unfamiliar terminology and assess potential harm versus benefit to their baby and themselves, often when an urgent intervention is required. Time pressures of intrapartum interventions are a major challenge for recruitment discussions taking place during labour, with research midwives expected to present, discuss and answer questions whilst maintaining equipoise. However, little is known about these interactions. An integrated qualitative study (IQS) was used to investigate information provision for women invited to participate in the Assist II feasibility study investigating the OdonAssist™—a novel device for use in assisted vaginal birth with an aim to generate a framework of good practice for information provision.MethodsTranscripts of in-depth interviews with women participants (n = 25), with recruiting midwives (n = 6) and recruitment discussions between midwives and women (n = 21), accepting or declining participation, were coded and interpreted using thematic analysis and content analysis to investigate what was helpful to women and what could be improved.ResultsRecruiting women to intrapartum research is complicated by factors that impact on women’s understanding and decision-making. Three key themes were derived from the data: (i) a woman-centred recruitment process, (ii) optimising the recruitment discussion and (iii) making a decision for two.ConclusionDespite evidence from the literature that women would like information provision and the research discussion to take place in the antenatal period, intrapartum studies still vary in the recruitment processes they offer women. Particularly concerning is that some women are given information for the first time whilst in labour, when they are known to feel particularly vulnerable, and contextual factors may influence decision-making; therefore, we propose a framework for good practice for information provision for research involving interventions initiated in the intrapartum period as a woman centred, and acceptable model of recruitment, which addresses the concerns of women and midwives and facilitates fair inclusion into intrapartum trials.Trial registrationISRCTN. This qualitative research was undertaken as part of the ASSIST II Trial (trial registration number: ISRCTN38829082. Prospectively registered on 26/06/2019).

Predictors of childbirth experience: Prospective observational study in eastern Spain

BackgroundIn recent years, birth experience has been highlighted by national and international organisations as a relevant value in measuring maternal health care quality. According to a standardised tool, we aimed to assess which clinical indicators had the most significant influence on the birth experience. MethodsThis prospective observational study was carried out in fourteen hospitals in eastern Spain. 749 women consented to the collection of birth variables at discharge, and subsequently, at 1–4 months, data were collected on the birth experience as measured by the Spanish version of the Childbirth Experience Questionnaire. Next, a linear regression analysis was performed to determine which clinical birth indicators greatly influence the birth experience measure. ResultThe study sample (n = 749) was predominantly Spanish and primipara, with 19.5% vaginal births. The predictors that emerged in the linear regression model were to have a birth companion (B = 0.250, p = 0.028), drink fluids during labour (B = 0.249, p < 0.001), have early skin-to-skin contact (B = 0.213, p < 0.001) and being transferred to a specialised room for the second stage of labour (B = 0.098, p = 0.016). The episiotomy (B = -0.100, p < 0.015) and having an operative birth (B = -0.128, p < 0.008) showed a negative influence. ConclusionOur study supports that intrapartum interventions recommended according to clinical practice guidelines positively influence the mother's birth experience. Episiotomy and operative birth should not be used routinely as they negatively influence the birth experience.

Impact of an intrapartum care quality improvement intervention in Brazilian private hospitals on care safety measures and adverse outcomes

BackgroundIn 2015, a quality improvement (QI) intervention to reduce cesarean sections (CS)—the Adequate Childbirth Project (PPA)—was implemented in the private sector in Brazil. This analysis aims to compare safety care measures and adverse outcomes between women exposed to the PPA intervention to those receiving standard care.MethodsThe analysis included a convenience sample of 12 private hospitals that participated in the PPA (2017–2018). Data collection was performed through chart review and interviews. Differences in 15 outcomes were examined using Pearson’s chi-square test and multiple logistic regressions.ResultsThe final weighted sample was comprised of 4789 births, 2570 in the PPA group (53.5%) and 2227 in the standard care group (46.5%). CS rate was significantly lower in the PPA group (67.3% vs 88.8%). After adjusting for potential confounders, PPA model was associated with decreased overall CS rate (OR = 0.30, 95% CI 0.24 to 0.36), as well as prelabor (OR = 0.41, 0.34 to 0.48) and repeated CS (OR = 0.45, 0.29 to 0.70). In terms of other safety care measures, women in the PPA model had an increased chance of absence of antibiotic prophylaxis in Group B Streptococcus (GBS) + women (OR = 4.63, 1.33 to 16.14) and for CSs (OR = 1.75, 1.38 to 2.22), while those with severe hypertension were less likely to not receiving magnesium sulphate (OR = 0.27, 0.09 to 0.77). Regarding obstetric and neonatal outcomes, PPA model was associated with a decreased chance of having an obstetric anal sphincter injury (OASI) following an episiotomy (OR = 0.34, 0.13 to 0.89), requiring antibiotics other than routine prophylaxis (OR = 0.84, 0.70 to 0.99), having a late preterm (OR = 0.36, 0.27 to 0.48) or early term baby (OR = 0.81, 0.70 to 0.94). There were no statistically significant differences for other outcomes.ConclusionsThe PPA intervention was able to reduce CS rates, late preterm and early term deliveries without increasing the chance of adverse outcomes. The bidirectional effect on safety care measures reinforces that QI initiatives includes closer observation of routine care when implementing interventions to reduce C-section rates.

Antepartum and intrapartum stillbirth rates across gestation: a cross-sectional study using the revised foetal death reporting system in the U.S.

BackgroundThere is a renewed call to address preventable foetal deaths in high-income countries, especially where progress has been slow. The Centers for Disease Control and Prevention released publicly, for the first time, the initiating cause and estimated timing of foetal deaths in 2014. The objective of this study is to describe risk and characteristics of antepartum versus intrapartum stillbirths in the U.S., and frequency of pathological examination to determine cause.MethodsWe conducted a cross-sectional study of singleton births (24–43 weeks) using 2014 U.S. Fetal Death and Natality data available from the National Center for Health Statistics. The primary outcome was timing of death (antepartum (n = 6200), intrapartum (n = 453), and unknown (n = 5403)). Risk factors of interest included maternal sociodemographic, behavioural, medical and obstetric factors, along with foetal sex. We estimated gestational week-specific stillbirth hazard, risk factors for intrapartum versus antepartum stillbirth using multivariable log-binomial regression models, conditional probabilities of intrapartum and antepartum stillbirth at each gestational week, and frequency of pathological examination by timing of death.ResultsThe gestational age-specific stillbirth hazard was approximately 2 per 10,000 foetus-weeks among preterm gestations and > 3 per 10,000 foetus-weeks among term gestations. Both antepartum and intrapartum stillbirth risk increased in late-term and post-term gestations. The risk of intrapartum versus antepartum stillbirth was higher among those without a prior live birth, relative to those with at least one prior live birth (RR 1.32; 95% CI 1.08–1.61) and those with gestational hypertension, relative to those with no report of gestational hypertension (RR 1.47; 95% CI 1.09–1.96), and lower among Black, relative to white, individuals (RR 0.70; 95% CI 0.55–0.89). Pathological examination was not performed/planned in 25% of known antepartum stillbirths and 29% of known intrapartum stillbirths.ConclusionThese findings suggest greater stillbirth risk in the late-term and post-term periods. Primiparous mothers had greater risk of intrapartum than antepartum still birth, suggesting the need for intrapartum interventions for primiparous mothers in this phase of pregnancy to prevent some intrapartum foetal deaths. Efforts are needed to improve understanding, prevention and investigation of foetal deaths as well as improve stillbirth data quality and completeness in the United States.

Effect of intra-partum azithromycin on the development of the infant nasopharyngeal microbiota: A post hoc analysis of a double-blind randomized trial.

SummaryBackgroundSepsis is a leading cause of neonatal death. Intrapartum azithromycin reduces neonatal nasopharyngeal carriage of potentially pathogenic bacteria, a prerequisite for sepsis. Early antibiotic exposure has been associated with microbiota perturbations with varying effects. This study aims to understand the effect of intrapartum azithromycin intervention on the developing nasopharyngeal microbiota of the child.MethodsUsing 16S rRNA gene sequencing, we analysed the microbiota of 343 nasopharyngeal samples collected from birth to 12 months from 109 healthy infants selected from a double-blind randomized placebo-controlled clinical trial conducted in the Gambia (PregnAnZI-1). In the trial, 829 women were given 2g oral azithromycin or placebo (1:1) during labour with the objective of reducing bacterial carriage in mother and child during the neonatal period. The post-hoc analysis presented here assessed the effect of the intervention on the child nasopharyngeal microbiota development.Findings55 children were from mothers given azithromycin and 54 from mothers given placebo. Comparing arms, we found an increase in alpha-diversity at day-6 (p = 0·018), and a significant effect on overall microbiota composition at days 6 and 28 (R2 = 4.4%, q = 0·007 and R2 = 2.3%, q = 0·018 respectively). At genus level, we found lower representation of Staphylococcus at day-6 (q = 0·0303) and higher representation of Moraxella at 12 months (q = 0·0443). Unsupervised clustering of samples by microbial community similarity showed different community dynamics between the intervention and placebo arms during the neonatal period.InterpretationThese results indicate that intrapartum azithromycin caused short-term alterations in the nasopharyngeal microbiota with modest overall effect at 12 months of age. Further exploration of the effects of these variations on microbiome function will give more insight on the potential risks and benefits, for the child, associated with this intervention.FundingThis work was jointly funded by the Medical Research Council (UK) (MC_EX_MR/J010391/1/MRC), Bill & Melinda Gates Foundation (OPP1196513), and MRCG@LSHTM Doctoral Training Program.